Questionnaire

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This is an excerpt from an Occupational and Environmental Medicine packet developed by Dr. Grace Ziem. It is 18 pages in its entirety. I thought it might help to see the types of questions that address the issue of environmental illness. These symptoms can mean something entirely unrelated so this is not meant to diagnose.



In the questionnaire you are asked to rate the severity of your symptoms on a 0 to 10 scale.



a. Problems with your head, such as headaches, or a feeling of pressure or fullness in your face or head?



b. Problems with your ability to think, such as difficulty concentrating or remembering things, feeling spacey, or having trouble making decisions?



c. Problems with your mood, such as feeling tense or nervous, irritable, depressed, having spells of crying or rage, or loss of motivation to do things that used to interest you?



d. Problems with your balance or coordination, with numbness or tingling in your extremities, or with focusing your eyes?



e. Problems with your muscles or joints such as pain, aching, cramping, stiffness or weakness?



f. Problems with your skin such as a rash, hives, or dry skin?



g. Problems with your urinary tract such as pelvic pain or frequent or urgent urination?



h. Problems with your stomach or digestive tract, such as abdominal pain or cramping, abdominal swelling or bloating, nausea, diarrhea, or constipation?



i. Problems with your heart or chest, such as a fast or irregular heart rate, skipped beats, your heart pounding, or chest discomfort?



j. Problems with burning or irritation of your eyes or problems with your airway or breathing, such as feeling short of breath, coughing, or having a lot of mucus, postnasal drainage, or respiratory infections?



Again, these are research questions only and, frankly, the tip of the iceberg when it comes to biotoxin exposure.