Toxin+Exposure+Questionnaire v3

Toxin Exposure Questionnaire
Patient Name________________________________________________________________ Date____________________
Please check the best response for each of the following questions. Your provider will discuss your answers with you.
FOOD & WATER YES SOMETIMES IN THE PAST NO

1. Do you consume conventionally-farmed (non-organic) or genetically- o o o o
modified fruits and vegetables?
2. Do you consume conventionally-raised (non-organic) animal products o o o o

(i.e., meat, poultry, dairy, eggs)
3. Do you consume canned or farmed fish and seafood? o o o o

4. Do you consume processed foods (i.e., foods with added artificial o o o o
colors, flavors, preservatives, or sweeteners), deep-fried, or fast foods?
5. Do you drink water from a well, spring, or cistern, or from plumbing o o o o

pipes or fixtures installed before 1986?
6. Do you drink sodas, juices, or other beverages with natural or o o o o

refined sweeteners (i.e., high-fructose corn syrup, cane sugar, agave
nectar, Stevia, undiluted fruit juice, etc.) or artificial sweeteners (i.e.,
NutraSweet/Equal/aspartame, Sweet’N Low/saccharine, Splenda/
sucralose, Sunett/Sweet One/acesulfame K, neotame)?
HOME & WORK ENVIRONMENT YES SOMETIMES IN THE PAST NO

1. Do you live in an apartment or home built before 1978, or in a mobile o o o o
home, boat, or RV?
2. Does your home or workplace contain new construction materials or o o o o

furniture (i.e., paint, laminate flooring, particle board, new carpeting,
bedding, furniture, etc.)?
3. Does your home or workplace show signs of mold or water damage o o o o

(i.e., cracking paint, ceiling leaks, decaying insulation or foam, visible
mold, or damp windows, basement, or crawlspaces, etc.)?
4. Are you exposed to toxic substances (i.e., treated lumber, lead paint, o o o o
paint chips or dust, broken mercury thermometers or fluorescent bulbs,
etc.) at home or work?
5. Are you exposed to conventional cleaning chemicals, disinfectants, o o o o

hand sanitizers, air fresheners, scented candles, or other scented
products at home or work?
6. Do you live or work near an industrial pollution source (i.e., highway, o o o o

factory, incinerator, gas station, power plant, etc.)?
7. Do you live or work near a source of electromagnetic radiation (i.e., o o o o

cell phone tower, high-voltage power lines, or other known source)?
8. Do you live or work in an agricultural area or another type of area o o o o

where you are exposed to herbicides, pesticides, or fungicides?
9. Do you have wood-burning, propane, or gas stoves or appliances at o o o o

home or work?
10. Do you live or work in a sealed building with recirculated air? o o o o
Version 3 © 2017 The Institute for Functional Medicine

TRAVEL & RECREATION YES SOMETIMES IN THE PAST NO
1. Do you frequent parks, golf courses, or other outdoor or recreational o o o o
areas treated with herbicides, pesticides, or fungicides?
2. Do you travel by air? o o o o

3. Do you run or bike to work along busy streets? o o o o
4. Do you get sick while camping, hiking, or traveling (foreign o o o o
or domestic)?
5. Are you exposed to toxic chemicals as a result of a hobby (i.e., paints, o o o o

photo-developing chemicals, epoxy adhesives, glues, varnishes, etc.)?
MEDICAL & PERSONAL CARE YES SOMETIMES IN THE PAST NO

1. Are you sensitive to personal care products like lotions, moisturizers, o o o o
toners, shampoos, conditioners, shaving creams, and soaps?
2. Are you sensitive to smoke, perfumes, fragrances, cleaning products, o o o o

gasoline, or other fumes?
3. Do you smoke, or are you often exposed to second-hand smoke? o o o o

4. Do you have a history of heavy use of alcohol, or recreational or o o o o
prescription drugs?
5. Do you have any unusual reactions to anesthesia or to prescription or o o o o

over-the-counter medications?
6. Do you have root canals, extracted teeth, “silver” fillings, crowns, o o o o

dental sealants, dentures, retainers, aligning trays, braces, mouth
guards, dental implants, etc.?
7. Do you have food reactions, sensitivities, or intolerances? Do you have o o o o

environmental allergies?
8. Do you have any artificial materials in your body (implants, pins, o o o o

joints, etc.)?
9. Do you lead a high-stress lifestyle, or have you experienced a stressful o o o o

or traumatic event?
Note: For more information on the questions included here, please see the Toxin Exposure Questionnaire—Bibliography
in IFM’s Clinical Practice Toolkit.
© 2017 The Institute for Functional Medicine

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Toxin Exposure Questionnaire

Patient Name________________________________________________________________ Date____________________

FOOD & WATER YES SOMETIMES IN THE PAST NO

2. Do you consume conventionally-raised (non-organic) animal products o o o o

3. Do you consume canned or farmed fish and seafood? o o o o

5. Do you drink water from a well, spring, or cistern, or from plumbing o o o o

6. Do you drink sodas, juices, or other beverages with natural or o o o o

HOME & WORK ENVIRONMENT YES SOMETIMES IN THE PAST NO

2. Does your home or workplace contain new construction materials or o o o o

3. Does your home or workplace show signs of mold or water damage o o o o

5. Are you exposed to conventional cleaning chemicals, disinfectants, o o o o

6. Do you live or work near an industrial pollution source (i.e., highway, o o o o

7. Do you live or work near a source of electromagnetic radiation (i.e., o o o o

8. Do you live or work in an agricultural area or another type of area o o o o

9. Do you have wood-burning, propane, or gas stoves or appliances at o o o o

10. Do you live or work in a sealed building with recirculated air? o o o o

Version 3 © 2017 The Institute for Functional Medicine

2. Do you travel by air? o o o o

5. Are you exposed to toxic chemicals as a result of a hobby (i.e., paints, o o o o

MEDICAL & PERSONAL CARE YES SOMETIMES IN THE PAST NO

2. Are you sensitive to smoke, perfumes, fragrances, cleaning products, o o o o

3. Do you smoke, or are you often exposed to second-hand smoke? o o o o

5. Do you have any unusual reactions to anesthesia or to prescription or o o o o

6. Do you have root canals, extracted teeth, “silver” fillings, crowns, o o o o

7. Do you have food reactions, sensitivities, or intolerances? Do you have o o o o

8. Do you have any artificial materials in your body (implants, pins, o o o o

9. Do you lead a high-stress lifestyle, or have you experienced a stressful o o o o

© 2017 The Institute for Functional Medicine

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Patient Name____________________________________________ Date