Neurotoxic Questionaire - Mosaic Wellness Hub

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How did you hear about our Wellness and Nutrition Program?

What is your major complaint? Please list when each symptom began and be as descriptive as possible:

Please list your current and past health conditions (i.e. Diabetes Mellitus, etc.):

Is there anything else in your medical history that you consider to be relevant? (Even from childhood)

What is your employment history? Please provide brief summary including dates if possible.

Please list your past or present Hobbies that could be sources of toxicity or chemicals:

How often are you involved in these Hobbies currently?

Please list past or present allergies, including allergies to medications.

Please list all past surgeries and the condition each surgery was for, including dates.

Please explain your housing history (type of homes, where and when).

Patient History

Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank.

Do you have amalgam (silver) fillings in your teeth?

Yes

If you had amalgams removed, was it done by a biological dentist using a safe protocol?

Yes

Did your mother have amalgam when pregnant with you?

Yes

Do you have any dental implants, retainers or other metal in your mouth?

Yes

Did you wear contact lenses during the 1980’s or early 1990’s?

Yes

Did you take oral contraceptives during the 1980’s or early 1990’s?

Yes

Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?

Yes

Have you noticed any adverse reactions to these shots?

Yes

Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

Yes

Does your occupation involve soldering or metal salvage?

Yes

Have you done any old home repair or sandblasting?

Yes

Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)

Yes

Are you around a lot of fake leather, or vinyl?

Yes

Have you ever lived near, on or by a golf course, freeway or tension wires?

Yes

Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)

Yes

Do you have your house sprayed with pesticides for pest control?

Yes

Do you spray herbicide (weed killers) in or around your home?

Yes

Do you use conventional insect repellants on your self or family?

Yes

Do you use conventional perfume or cologne every day?

Yes

Do you use air freshener in your house, work or car?

Yes

Do you have a water filtration system for your entire house or shower filtration?

Yes

Does your spouse or other family members work around chemicals?

Yes

Can you think of any other toxic exposures you may have had?

Yes

Do you see mold growing at home, work or school?

Yes

Have you ever had water damage at home, work or school?

Yes

Does your home, workplace or school have a damp or mildew smell?

Yes

Does spending time in your basement cause or worsen your symptoms?

Yes

Does your basement or crawl space have a sump pump?

Yes

Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?

Yes

Does anyone in your home have asthma like symptoms?

Yes

Does anyone in your family have chronic sinus infections or irritations?

Yes

Have you ever been diagnosed with Lyme Disease?

Yes

Have you had dry sockets or infected tooth extractions?

Yes

Have you ever been bitten by a tick or recluse spider?

Yes

Have you ever seen a bulls-eye rash appear on any part of your body?

Yes

Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?

Yes

Was your mother ever diagnosed with Lyme Disease?

Yes

Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition?

Yes

Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

Yes

Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

Yes

Does anyone in your family experience similar symptoms to yours?

Yes

What is your birth order (i.e. first born, second, third, etc.)?

Do you or any immediate family member have a history with cancer?

Yes

Do you have any history of heart disease, myocardial infarction (heart attack), etc.?

Yes

Are you currently having any thoughts of suicide?

Yes

Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?

Yes

Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?

Yes

Have you ever been in an auto accident, fallen or received a major physical injury?

Yes

Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, Brussels sprouts or other vegetables?

Yes

Do you often have gas that has a sulfur or foul smell?

Yes

Have you ever been vegan or vegetarian for any length of time?

Yes

Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?

Yes

Have you taken birth control or Hormone replacement therapy for any length of time?

Yes

If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

Yes

Have been on antibiotics for any extended period of time or often as a child or adult?

Yes

Does your gut temporarily feel better after a round of antibiotics?

Yes

How many times a day are you having a bowel movement?

Point Scale

Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. 0-Never had the symptom. 1-Occasional,mild effect 2-Occasional,severe effects 3-Frequent,mild effect 4-Frequent,severe effect

Excessive shyness, timidity, social phobia (not typical to your personality)

0 1 2 3 4

Irritability (not typical to your personality)

0 1 2 3 4

Insomnia (can’t get to sleep or return to sleep)

0 1 2 3 4

Sound in ears (ringing or hearing your heart beat)

0 1 2 3 4

Psychological symptoms, even thoughts of suicide

0 1 2 3 4

Floaters, shadows or swimmers when you read or look into the sky

0 1 2 3 4

Dyslexia or loss of place while reading, even as a child

0 1 2 3 4

Peeling on top layer of skin (hands, feet)

0 1 2 3 4

Heart pain (angina) and you are under 45 years old

0 1 2 3 4

Gout (arthritic pain, especially in big toes)

0 1 2 3 4

Anemia (low iron/hemoglobin on blood test)

0 1 2 3 4

Wrist/ankle drop or weak extensor muscles

0 1 2 3 4

Hair falls out (not normal male pattern baldness)

0 1 2 3 4

Bad night vision or seeing halos around lights

0 1 2 3 4

Shortness of breath, with very little effort

0 1 2 3 4

Excessive thirst and/or frequent urination

0 1 2 3 4

Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners

0 1 2 3 4

Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.)

0 1 2 3 4

Joint pain-not necessarily true arthritis-can move from joint to joint

0 1 2 3 4

Difficulty losing weight regardless of diet or exercise

0 1 2 3 4

Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis

0 1 2 3 4

Frequent illness, prolonged illness or sick days

0 1 2 3 4

Trouble adding or dividing numbers in your head

0 1 2 3 4

Frequent muscle aches, cramps, unusual sharp sudden pains

0 1 2 3 4