Full Name *

Phone *

Email *

Date of birth *

1. Mercury Exposure. Check all that apply:

i) I have silver dental fillings (amalgams) in my mouth. If Yes, how many?

ii) I had amalgam/silver filings, but they have been removed. If Yes, how many and when?

iii) Been employed or worked in the Dental field (e.g. Dentist, Dental Assistant, etc.)?

iv) Been exposed to mercury or its vapor through your work?

v) Lived near a coal-fired power plant?

vi) Had seafood as a regular part of your diet (e.g., sushi, tuna, swordfish, shark, kingfish)?

vii) I have NONE of the above

viii)Others (please specify).

2. Symptomatic. (select all that apply):

3. Energetic. (select all that apply):

Select options *

Easily fatigued, often when there is no real underlying reason

Tired nearly ALL the time Chronic Fatigue Syndrome

Neither of the above I have good energy levels.

None of the above

4. Emotional. (check all that apply):

Select from options *

5. Diagnostic. (check all that apply):

i) Heavy metal toxicity. If Yes, which metals.

ii) Mineral Deficiency. If Yes, which minerals.

iii) Cardiac (heart) problems such as arrhythmia (irregular heartbeat), congestive heart failure or angina?

iv) Shortness of breath?

v) Hypertension?

vi) Infertility, poor sperm motility or count?

vii) Autoimmune diseases such as Lupus, Fibromyalgia, Rheumatoid Arthritis?

viii) Kidney (renal) disease?

ix) Has anyone in your family tree had dementia or Alzheimer disease?

x) I have NONE of the above

xi) Others (please specify).

6. Neurologic. (check all that apply):

Select applicable option *

Numbness, tingling, or paresthesia (burning, prickling, itching, with no apparent physical cause) of the skin or extremities?

Muscle twitching, tremors, balance problems, or restless leg syndrome?

Vision defects that are not explained by aging or correctable with eyeglasses?

Multiple Sclerosis, A.L.S. (Lou Gehrigs disease), Parkinson disease?

Other chronic neurodegenerative disease?

NONE of the above

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