How do we contact you?

Please answer the following questions:

1. Does exposure to cigarette smoke and/or perfume cause you
   to experience symptoms?
   
2. Do you notice more symptoms at work than at home -- or visa versa?
   
3. Do you have frequent headaches or migraines?
   
4. Has your productivity level decreased substantially over the
   past few months or years?
   
5. Do you have allergy symptoms and/or repeated bouts of sinusitis, bronchitis,
   nasal polyps, chronic ear and throat infections or ringing in the ears?
   
6. Have you been diagnosed with chronic fatigue syndrome, Epstein Barr Virus,
   cytomegalovirus, herpes virus -- or do you have an overwhelming fatigue?
   
7. Does your work or do your hobbies expose you to toxic minerals,
   metals or chemicals?
   
8. Have you been diagnosed with irritable bowel syndrome or do you have
   frequent nausea, bloating, constipation or diarrhea?
   
9. Do you experience chronic muscle and joint aches and pains -- or have you been diagnosed
   with fibromyalgia?
   
10. Do you routinely have your home and/or yard sprayed with pesticides?
    
11. Do you frequently experience forgetfulness, difficulty concentrating,
    or numbness and tingling?
    
12. Have you had a positive ANA (antinuclear antibody) test or do you have M.S., lupus,
    rheumatoid arthritis, an autoimmune disease or a history of cancer?
    
13. Do you have or have you had breast implants, and did you see a correlation
    between implantation and the beginning of your symptoms?
    
14. Has any type of metal been used in implants or joint replacements in your body?
    Can the onset of your health problems be traced to the time of the implant?
    
15. Do you have named cardiovascular disease without knowing the cause?
    
16. Miscellaneous Questions or Concerns
    

If you answered "yes" to three or more of these questions, you could have environment-related illness.
Send this form on to us -- we'll give you feedback on your responses.