Environmental Exposure Questionnaire

The purpose of an environmental exposure questionnaire is to identify potential sources of toxins and contaminants that an individual may be exposed to in their daily life. By understanding these exposures, you can better understand how to eliminate them from your daily life or at a minimum reduce the burden of these toxins on the body. This questionnaire is not to be used as a replacement for medical care by your healthcare professional.

Instructions: Please answer the following questions to the best of your knowledge. Some questions might be repeated.

Section 1: General Environmental Exposure

  1. Do you live in a city or near a major roadway?
  2. Do you use conventional household cleaning products?
  3. Do you use conventional personal care products (e.g. shampoo, lotion, deodorant)?
  4. Do you live in a house built before 1978 (may contain lead-based paint)?
  5. Do you live near an agricultural area or golf course (may be exposed to pesticides)?
  6. Do you live near a landfill or waste incinerator?
  7. Have you been exposed to radiation (e.g. x-rays, CT scans, nuclear power plants)?
  8. Do you live or work near a factory or industrial area?
  9. Have you used pesticides or insecticides on your property or garden?
  10. Do you live near or use a landfill or waste disposal site?
  11. Have you used or been exposed to cleaning chemicals or solvents at work or at home?
  12. Have you been exposed to tobacco smoke, either firsthand or secondhand?
  13. Do you frequently use hair dye or other hair products that contain chemicals?
  14. Have you used or been exposed to personal care products that contain parabens or phthalates?
  15. Have you been exposed to lead, mercury, or other heavy metals, either through work or in the environment?
  16. Have you been exposed to electromagnetic fields (EMFs) from electronic devices or power lines?
  17. Do you live in an area with high air pollution, such as near a busy roadway or industrial plant?
  18. Have you been exposed to mold or fungi in your home or workplace?
  19. Have you been exposed to radiation, either through medical procedures or environmental sources?
  20. Do you live near a farm or agricultural area where pesticides and herbicides are commonly used?
  21. Have you been exposed to asbestos, either through work or in your home or community?
  22. Have you been exposed to phthalates or other chemicals in plastics, either through food packaging or personal use products?
  23. Have you been exposed to flame retardants, either through furniture or clothing?
  24. Do you frequently use air fresheners or scented candles that contain synthetic fragrances?
  25. Have you been exposed to volatile organic compounds (VOCs) from paint, carpets, or building materials?
  26. Have you been exposed to chlorine or other disinfectants in your drinking water?

Total: ____________________

Section 2: Food Based Toxins

  1. Do you consume conventional (non-organic) fruits and vegetables regularly?
  2. Do you consume meat from conventionally-raised animals (non-organic, grain-fed, etc.)?
  3. Do you consume seafood that may be contaminated with heavy metals or other toxins (e.g. tuna, swordfish, farmed fish, etc.)?
  4. Do you consume foods that have been processed or packaged with preservatives, additives, or artificial colors/flavors?
  5. Do you consume products containing high amounts of refined sugar or artificial sweeteners?
  6. Do you consume foods that have been contaminated with mold or mycotoxins (e.g. peanuts, corn, wheat, etc.)?
  7. Do you consume foods that may be contaminated with pesticides or herbicides (e.g. non-organic grains, nuts, and seeds)?
  8. Do you use non-stick cookware or cookware that may leach harmful chemicals into your food (e.g. aluminum, copper, etc.)?
  9. Do you use plastic containers or wrap that may contain harmful chemicals (e.g. BPA, phthalates, etc.) to store or heat your food?
  10. Do you filter your drinking water?
  11. Do you drink alcoholic beverages?
  12. Do you consume sodas, juices, or other beverages that have sugars or sweeteners?
  13. Do you consume canned or farmed fish?
  14. Do you frequently consume canned foods and beverages that may contain BPA or other chemicals from the can lining?
  15. Do you consume artificial sweeteners, flavors, and colors in your food and beverages?
  16. Do you frequently consume fast food or eat out at restaurants that may use low-quality, processed ingredients?
  17. Do you frequently eat fried or grilled foods that may contain harmful compounds, such as acrylamide or heterocyclic amines?

Total: ____________________

Section 3: Hormone Disrupting Toxins

  1. Do you use any personal care products such as lotions, shampoos, or perfumes on a daily basis?
  2. Have you ever used birth control pills or hormone replacement therapy?
  3. Do you consume any processed or packaged foods regularly?
  4. Do you consume non-organic meat or dairy products?
  5. Do you use plastic containers or wrap to store or reheat food?
  6. Do you live or work near any industrial sites or agricultural areas that may use pesticides or other chemicals?
  7. Do you regularly use household cleaning products or air fresheners?
  8. Do you consume any soy-based products or supplements?
  9. Do you use any herbicides or pesticides in your garden or lawn?
  10. Do you live in an older building that may contain lead-based paint or other environmental toxins?
  11. Do you consume any seafood or fish regularly?
  12. Do you use any synthetic fragrances or candles in your home?
  13. Have you ever had a hormone-related health issue such as PCOS, endometriosis, or fibroids?
  14. Do you regularly consume soy products?
  15. Do you use any plastic or vinyl products such as shower curtains or vinyl flooring?
  16. Have you ever had a hormone-related cancer such as breast or prostate cancer?
  17. Do you consume any bottled water or use a plastic water bottle regularly?
  18. Do you use any antibacterial soaps or cleaning products?

Total: ____________________

Section 4: Heavy Metals

  1. Have you worked in a profession or industry where exposure to heavy metals is common?
  2. Do you live by an airport?
  3. Do you consume fish or shellfish regularly?
  4. Have you ever had any dental work that involved amalgam fillings?
  5. Do you drink tap water that may contain heavy metals, such as lead or arsenic?
  6. Do you live in a home that was built before 1978 and may contain lead paint?
  7. Have you ever been exposed to lead in the workplace or through hobbies, such as soldering or stained glass making?
  8. Have you ever lived near a factory or industrial area that may have released heavy metals into the air or water?
  9. Have you ever worked with or been exposed to batteries, electronics, or other products that contain heavy metals?
  10. Do you smoke cigarettes or use other tobacco products, which may contain heavy metals?
  11. Have you ever been exposed to mercury through broken thermometers, fluorescent light bulbs, or other sources?
  12. Have you ever experienced symptoms that could be related to heavy metal toxicity, such as fatigue, brain fog, or unexplained pain?

Total: ____________________

Calculating your Environmental Exposure Score

To evaluate your environmental exposure based on the questionnaire, please follow the instructions below to tally your “yes” answers, which indicate exposure to certain environmental factors:

  1. Carefully review your responses to each question in the questionnaire.
  2. For each “yes” answer, assign a score of 1.
  3. Add up the total number of “yes” answers to calculate your overall exposure score.
    • Section 1 + Section 2 + Section 3 + Section 4 = Total overall exposure score

Total: ____________________

Your total exposure score will provide you with a rough estimation of your environmental exposure to various toxins. Please note that this score is not an absolute measure of your exposure, but rather a general indication of the potential risk factors in your environment. The higher your score, the more significant your exposure to environmental toxins may be. Use this information to help guide your detoxification efforts and work towards reducing your exposure to harmful substances.