Toxin Exposure Assessment

HARRIS INTEGRATED HEALTH AND NUTRITION

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Toxin Exposure Assessment

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Name *

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Last

Address *

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City

State

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Occupation *

Phone Number *

Height *

Weight *

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

cOMMUNITY Home and/or Work Environment

Do You Have Regular Exposure To; *

Automobile Exhaust Farm/Industrial Power Plant or Lines Radio Tower Landfill/Dump Hydro Tower

Do You Live in a; *

Do You Work in a; *

Bathing Showering Water Source; *

Do You Have; *

Allergies Sensitivity to Smells (gas, perfume, paint, etc.) Artificial Materials in the Body (implants, pins, joints, etc. Immunizations

Have You Ever; *

Used Tobacco Experimented with Recreational Drugs Led a High Stress Lifestyle Experienced a Stressful or Traumatic Event Been Under Anesthesia Had an Illness During Foreign Travel Had an Illness While Camping or Hiking Had Food Poisoning

Do You Have Regular Exposure at Home or Work To; *

Forced Air Heat Renovations (new carpets, add ons, etc. Basement Cracks or Dirt Floor Damp Basement or Crawl Space Wet Window or Outside Closet Walls Water Leaks (ceilings, walls, floors) Visible Mold Old or Cracking Ceiling Tiles Old or Cracking Vinyl Linoleum Flooring Crumbling Pipe Insulation Crumbling Wall or Ceiling Insulation Old or Cracking Paint Carpets or Rugs Stagnant or Stuffy Air Gas or Propane Stove Coal or Wood Stove Other Gas Appliance (water heater, furnace Regular Contact with Smokers Pesticides or Herbicides Harsh Chemicals (varnish, glue, gas, acid, etc. Welding or Soldering Metals (lead, mercury, etc. Paints Photo Developing/Dark Room Airplane Travel Cleaning Chemicals

dental Prescription or Over The Counter

Dental Exposures *

Do You Currently Have Amalgam fillings or Caps Have You removed or Lost Dental Fillings or Caps Did You Have Fillings as a Child Did You Have Your Wisdom Teeth Removed Do You Have Any Root Canal Treated Teeth Did Your Mother Have Dental Fillings Prior to Giving Birth to You

Please List All Drugs You Currently Take *

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