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Electromagnetic Factors
• • •
|
If lived near transformers, when
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|
Position of ur head of ur bed is
• • •
|
What is your occupation?
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|
Toxin Exposure
• • •
|
Formaldehyde
• • •
|
|
Had new carpets
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If yes, When
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|
Pesticides & Herbicides
• • •
|
Volatile Organic Compounds
• • •
|
|
Phenols-Do u use the following
• • •
|
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Been exposed to chemicals
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If yes, when
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|
home treated for termites
|
If yes, When
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|
Wash own vehicle by hand.
|
If yes, Type of cleaner
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|
Carbon Monoxide/Nitrogen Oxide/S
• • •
|
Ozone
• • •
|
|
Carbon Dioxide
• • •
|
Asbestos
• • •
|
|
Please note the Brand below
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|
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Shampoo
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Toothpaste
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|
Hair Conditioner
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Makeup
|
|
Lipstick
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Make-up Foundation
|
|
Deodorant
|
Perfume
|
|
Hairspray
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Shaving Cream
|
|
Cologne
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Facial Creams
|
|
Body Creams
|
|
|
have hair permanents?
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If yes, how often?
|
|
have hair colorings
|
If yes, Type
|
|
Do you use Latex products?
• • •
|
General Miscellaneous
• • •
|
|
Use a humidifier?
|
Last time you cleaned it
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|
Worked in beauty shop
|
When
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|
Usage of illicit drugs
|
If yes, What type
|
|
Work/worked on a farm
|
If yes, When
|
|
mercury fillings removed?
|
If yes, when
|
|
Been exposed to radiation
|
If yes, when
|
|
Live in an apartment?
|
How old?
|
|
For Women:
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|
|
Have breast implants
|
implant was made of
• • •
|
|
Metal been used in implants
|
What type?
|
|
Where
|
|
|
ever worked in a mall?
|
When?
|
|
Lived or traveled outside the US
|
Where?
|
|
Bought new furniture?
|
What type of material?
|
|
air filter in your bedroom
|
What type
|
|
Last time changed filter
|
|
|
Allow any pets in your room
|
What type
|
|
Describe content in bedroom
• • •
|
What type of mattress?
|
|
Art and Leisure Activities
• • •
|
What hobbies do you have
|
|
Occupation of your parents
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|
