Chemical Injury/Illness Survey

The purpose of this survey is to collect information about different diagnosis and symptoms of persons with Illness/injury related to chemicals or the environment. We have no interest in who you are or what street you live on. if there are more than one in your family with health problems related to chemicals please submit a separate form for each person.


Name (or nick name) : 
Address (City State):
Age: 
Male/female: 
Years Education: 
Degree Received: 
Please indicate your diagnosis with an (X)  
CFIDS: 
fibromyalgia: 
Asthma: 
Chemical Sensitivity (one chemical): 
Multiple Chemical Sensitivity: 
Porphyria: 
Food Sensitivities: 
Latex Allergies: 
Allergies: 
Please indicate your symptoms with an (X)  
Headaches
Allergic Asthma: 
Chemical irritant Asthma: 
Other Breathing problems: 
Decreased awareness to odors: 
Increased Awareness to odors: 
Bloating or other intestinal problems:
Short and long term memory loss: 
Flu-like symptoms
Dizziness: 
Mental confusion: 
Fatigue: 
Chronic exhaustion: 
Persistent skin rashes and sores: 
Muscle weakness and pains: 
Joint pain: 
Numbness and tingling: 
Ear, Nose and Throat problems: 
Cardiovascular irregularities: 
Cardiovascular spasm: 
Coronary heart disease: 
Arrhythmia: 
Genitourinary problems: 
Persistent infections, exp. yeast: 
learning disabilities: 
Food Allergies: 
Visual disturbance: 
Autoimmune disorders: 
Seizure disorders: 
Irritability: 
Behavioral problems: 
Inflammation: 
1-Other: 
2-Other: 
3-Other: 



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