Toxic Burden

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Occupation *

Phone Number *

Height *

Weight *

Marital Status *

Number of Children *

Today's Date *

Email *

Date of Birth *

Gender *

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW

Do you currently live (or were you raised) near a toxic waste or factory site, military base, industrial complex, agricultural area, or airport? *

Do you have a history of first-second-or third hand smoke exposure? *

Do you have any known environmental sensitivities, such as to odors like perfumeor diesel fuel? *

Do you have mercury fillings, work in the dental industry, eat fish more than 3 times a week, and/or have you ever been exposed to heavy metals, including lead? *

In total, do you use a microwave, cell phone, or laptop computer more than 3 hours a day? *

Do you have an occupational history with known exposure to toxic chemicals, such as asbestos or heavy metals? *

Do you use pesticides or herbicides in or around your home or garden or on your pets? *

Do find it difficult to sweat? *

Do you use any no organic body care or household cleaning products (e.g., shampoo or laundry detergent) and/or have your hair professionally dyed? *

Do you have your clothes dry-cleaned, use nonstick cookware, drink unfiltered water, or either drink from or store food in plastic containers? *

Submit

Toxic Burden

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW ​

PLEASE FILL OUT FORM AS BEST YOU CAN AND SUBMIT IT BY CLICKING THE BUTTON BELOW