Health Questionnaire – EHC-D Do you have environment-related illness? Take the following questionnaire to find out. We’ll give you feedback on your responses. asterisk (*) - Denotes required fields Step 1 of 3 33% Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Home PhoneWork PhoneEmail* This field is required to continue questionnaire. 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.