First Name *

Last Name *

Email *

Phone *

Vaccine Ingredient & Exposure History

Have you received any vaccinations?

Yes

If known, which vaccines have you received? (Vaccines that may contain heavy metals are bolded for easy reference.)

DTP/DTaP (Diphtheria, Tetanus, Pertussis) ⚠️

Tdap (Tetanus, Diphtheria, Pertussis - booster) ⚠️

Polio (IPV/OPV) ⚠️

MMR (Measles, Mumps, Rubella) ⚠️

Varicella (Chickenpox) ⚠️

Hepatitis A

Hepatitis B ⚠️

Pneumococcal (PCV/Prevnar)

Meningococcal (MenACWY, MenB)

HPV (Human Papillomavirus)

Shingles (Zoster)

Other

Routine & Childhood Vaccinations

I have received routine childhood vaccinations

have not received any routine vaccines

I prefer not to disclose my vaccination history

Please specify the vaccines you have received

COVID-19 Vaccination

I have received a COVID-19 vaccination

I have not received a COVID-19 vaccination

I prefer not to disclose my COVID-19 vaccine status

Were you informed about the ingredients in these vaccines?

Yes, I was told what was in my vaccines

No, I was not told what was in my vaccines

I am unsure

If known, which COVID-19 vaccine(s) have you received? (⚠️ indicates vaccines that may contain heavy metals)

Pfizer-BioNTech (Comirnaty) ⚠️

Moderna (Spikevax) ⚠️

AstraZeneca (Vaxzevria) ⚠️

Johnson & Johnson (Janssen) ⚠️

Sputnik V ⚠️

Sinopharm (BBIBP-CorV) ⚠️

Sinovac (CoronaVac) ⚠️

Covaxin ⚠️

Novavax ⚠️

Other

Please specify which COVID-19 vaccine have you received

Number of doses received

Unknown

Date of last COVID-19 vaccine dose (if known)

Were you informed about the ingredients in your COVID-19 vaccine?

Yes, I was told what was in my COVID-19 vaccine

No, I was not told what was in my COVID-19 vaccine

Routine Flu Shots & Possible Heavy Metal Exposure

I receive an annual flu shot (any brand)

I have received a flu shot in the past but do not receive it annually

I have never received a flu shot

I prefer not to disclose my flu shot history

If you have received a flu shot, do you know if it contained any preservatives or adjuvants?

I was not told whether my flu shot contained preservatives or adjuvants

I was told it contained Thimerosal (mercury-based preservative)

I was told it contained Aluminum-based adjuvants

Other

Were you told something else? Please specify

Are you concerned about any of the following vaccine ingredients? (Check all that apply)

Thimerosal (Mercury-based preservative) (Removed from most childhood vaccines but still in some flu shots)

Aluminum-based adjuvants (Aluminum hydroxide, Aluminum phosphate) (Used in Hepatitis A & B, DTP, HPV, Pneumococcal, Meningococcal vaccines)

Polysorbate 80 (Can increase blood-brain barrier permeability; used in HPV, COVID-19, flu shots)

Formaldehyde (Carcinogenic in high doses; used to inactivate viruses in vaccines)

SV40 (Simian Virus 40) (Linked to cancer; found in polio vaccines from 1955-1963, later removed)

Gelatin (from pigs) (Found in MMR, Chickenpox, Flu, Zoster vaccines; potential allergen & religious concern)

Egg protein (Used in flu vaccines; can trigger egg allergies)

Antibiotics (Neomycin, Streptomycin, Gentamicin, etc.) (Used to prevent bacterial contamination, potential allergen, gut microbiome disruption)

Residual DNA from animal/human cell lines (Used in some vaccines; ethical concerns, potential contamination risks, autoimmune concerns)

Monosodium glutamate (MSG) (Used in early vaccines; linked to neurotoxicity, excitotoxicity)

Other

If any other concerns, please specify

Have you experienced any adverse reactions or sensitivities to vaccines?

Yes

If you have experienced any adverse reactions or sensitivities to vaccines, please describe:

Would You Like Guidance on Vaccine Detoxification or Reducing Exposure to These Ingredients?

Yes

Heavy Metal Exposure History

Have you been exposed to any of the following common sources of Mercury (Hg)? (Check all that apply)

Dental fillings (amalgam/silver fillings)

Eating large fish (tuna, swordfish, shark, king mackerel)

Fluorescent light bulbs or thermometers (broken/exposure)

Industrial exposure (factory work, mining, waste disposal)

Other

If you have been exposed to any other sources of mercury, please specify:

Have you been exposed to any of the following common sources of Lead (Pb)? (Check all that apply)

Old homes (built before 1978, lead paint or pipes)

Drinking water from lead-contaminated pipes

Leaded gasoline exposure (before 1996)

Shooting ranges or handling ammunition

Imported toys, ceramics, or cosmetics with lead content (e.g., vintage or imported dishware, painted pottery, traditional kohl eyeliner, Sindoor, Surma, lipsticks from non-FDA-regulated sources)

Other

If you have been exposed to any other sources of lead, please specify:

Have you been exposed to any of the following common sources of Aluminum (Al)?

Cooking with aluminum pots, pans, or foil

Using aluminum-based deodorants (e.g., Dove, Secret, Degree, Old Spice, Gillette, Axe, Suave, Ban, Arrid, Mitchum)

Drinking from aluminum cans regularly (soda, energy drinks, beer)

Processed foods with aluminum-based additives (e.g., baking powder, processed cheese, coffee creamers, pickles, tortillas)

Antacids or medications containing aluminum (e.g., TUMS, Maalox, Rolaids, buffered aspirin)

Other

If you been exposed to any other sources of Aluminum (Al), please specify:

Have you been exposed to any of the following common sources of Arsenic (As)?

Drinking well water (especially in high-arsenic areas)

Eating non-organic rice or rice-based products frequently (e.g., white rice, brown rice, rice cakes, rice cereal, rice milk, rice protein powders, baby rice snacks)

Pesticide exposure (living near farms, using treated wood, or handling herbicides/insecticides) (e.g., Roundup/glyphosate, CCA-treated lumber, home pest control sprays)

Seafood (shellfish, seaweed, fish from contaminated waters)

Tobacco smoke exposure

Other

If you been exposed to any other sources of Arsenic (As), please specify:

Have you been exposed to any of the following common sources of Cadmium (Cd)?

Cigarette smoke (active or secondhand)

Welding or battery manufacturing exposure

Eating shellfish or kidney/liver meats frequently

Working in or living near industrial areas

Other

If you been exposed to any other sources of Cadmium (Cd), please specify:

Have you ever undergone heavy metal testing?

Yes

If you have undergone heavy metal testing, please specify type of test and results if known.

Have you experienced symptoms linked to heavy metal exposure?

Brain fog or memory issues

Chronic fatigue or low energy

Mood changes (anxiety, depression, irritability)

Digestive issues (bloating, nausea, diarrhea, constipation)

Frequent headaches or migraines

Joint pain or muscle weakness

Skin issues (rashes, eczema, unexplained irritation)

Hormonal imbalances (thyroid, reproductive issues)

Other

Would You Like Guidance on Identifying & Reducing Heavy Metal Exposure in Your Daily Life?

Yes

Fluoride Exposure (Toothpaste, Water and More)

Do you use fluoridated toothpaste?

Yes (e.g., Crest, Colgate, Sensodyne, Aquafresh, Arm & Hammer, Pepsodent)

No (I use fluoride-free toothpaste)

Unsure

Do you drink fluoridated water (city/municipal tap water)?

Yes (Most U.S. cities fluoridate their water; common in municipal water systems)

No (I drink well water, bottled water, or use a filtration system)

Unsure

Do you use a fluoride-free water filtration system?

Yes (e.g., reverse osmosis, Berkey with fluoride filters, distillation, activated alumina)

Unsure

Other Common Fluoride Exposure Sources (Check all that apply)

Processed beverages (e.g., soda, iced tea, bottled juice, sports drinks made with fluoridated water)

Coffee & tea (especially black & green tea, which naturally contain fluoride)

Teflon & non-stick cookware (fluorinated coatings like PTFE/PFOA)

Medications (e.g., fluoroquinolone antibiotics like Cipro, Prozac, Paxil, some anesthetics)

Infant formula (if mixed with fluoridated water)

Other

If you had any other fluoride exposure, please specify:

Have you ever followed a fluoride detox protocol?

Yes

If you have ever followed a fluoride detox protocol, please describe method and duration:

Would You Like Guidance on Reducing Fluoride Exposure & Choosing Safer Alternatives?

Yes

Pesticide & Herbicide Exposure

Have you had regular exposure to pesticides or herbicides? (Check all that apply)

Home use (e.g., Roundup, Ortho Weed B Gon, Spectracide, Sevin, Raid, OFF! bug spray)

Farm/agriculture work (handling crops, working in pesticide-treated fields)

Gardening with non-organic products (Miracle-Gro, Scotts, Bayer, synthetic fertilizers)

Nearby agricultural spraying (living near farms, golf courses, vineyards, or sprayed areas)

Pest control treatments (home fumigation, termite/pest control services, mosquito fogging)

Residue on clothing/shoes (after walking on treated lawns, parks, golf courses)

Do you regularly consume non-organic foods or beverages? (Check all that apply)

Non-organic grains & cereals (e.g., wheat, oats, rice, corn, granola bars, crackers)

Non-organic produce (e.g., strawberries, spinach, apples, potatoes, bell peppers, grapes)

Drinking water contamination (well water, rural areas with agricultural runoff)

If you had exposure to or consumed any other sources of pesticides and herbicides, please specify:

Would You Like Guidance on Minimizing Pesticide & Herbicide Exposure in Your Daily Life?

Yes

Household Chemical & Personal Care Product Exposure

Which cleaning products do you use? (Check all that apply)

Bleach-based cleaners (e.g., Clorox, Lysol, Soft Scrub, Tilex, Comet)

Ammonia-based cleaners (e.g., Windex, Mr. Clean, Glass Plus, floor waxes)

Antibacterial soaps & hand sanitizers (e.g., Dial, Bath & Body Works, Germ-X, Purell, soaps with Triclosan)

☐ Scented air fresheners & sprays (e.g., Febreze, Glade, Air Wick, plug-ins, scented candles)

Chemical laundry detergents & fabric softeners (e.g., Tide, Gain, Downy, Bounce, Arm & Hammer, Persil)

Non-toxic/natural cleaning products (e.g., Branch Basics, Dr. Bronner’s, Seventh Generation, vinegar, baking soda, essential oils)

If any other products, please specify:

Which personal care products do you use daily? (Check all that apply)

Aluminum-based deodorants/antiperspirants (e.g., Dove, Secret, Degree, Old Spice, Gillette, Axe, Suave, Ban, Arrid, Mitchum)

Fluoride toothpaste (e.g., Crest, Colgate, Sensodyne, Aquafresh, Pepsodent)

Synthetic skincare, shampoos, lotions (e.g., Neutrogena, Nivea, L’Oréal, Olay, Aveeno, Pantene, Head & Shoulders, Herbal Essences)

Fragrance-free/natural personal care (e.g., Native, Schmidt’s, Dr. Bronner’s, Tom’s of Maine, Weleda, Earth Mama)

If any other personal care products, please specify:

Would You Like Guidance on Reducing Exposure to Harmful Household Chemicals & Personal Care Products?

Yes

Processed Foods & Artificial Ingredients

Do you regularly consume fast food or takeout?

No, I do not eat fast food or takeout

Yes, regularly (multiple times per week)

Yes, occasionally (a few times per month)

Yes, but rarely (once a month or less)

I prefer not to disclose

If yes, which types of fast food or takeout do you consume most often? (Check all that apply)

Burgers & fries (e.g., McDonald’s, Burger King, Wendy’s, Five Guys, In-N-Out, Shake Shack)

Mexican fast food (e.g., Taco Bell, Chipotle, Qdoba, Del Taco)

Fried chicken (e.g., KFC, Popeyes, Chick-fil-A, Church’s, Raising Cane’s)

Pizza chains (e.g., Domino’s, Pizza Hut, Little Caesars, Papa John’s)

Sandwiches & subs (e.g., Subway, Jersey Mike’s, Jimmy John’s, Firehouse Subs)

Asian fast food (e.g., Panda Express, P.F. Chang’s, Teriyaki Madness, Pei Wei)

Breakfast fast food (e.g., Dunkin’, Starbucks, Tim Hortons, McDonald's breakfast, IHOP to-go)

Convenience store foods (e.g., 7-Eleven hot dogs, gas station food, roller-grill items)

If any other fast food, please specify:

Which of the following processed or pre-packaged foods do you consume regularly? (Check all that apply)

Candy & sweets (e.g., chocolate bars, gummy candies, licorice, hard candy, lollipops)

Sodas & sugary drinks (e.g., Coca-Cola, Pepsi, Mountain Dew, Sprite, fruit punch, energy drinks)

Packaged snack foods (e.g., chips, crackers, granola bars, popcorn, pretzels)

Frozen & microwavable meals (e.g., TV dinners, Hot Pockets, frozen pizza, instant mac & cheese)

Instant noodles & soups (e.g., ramen, Cup Noodles, canned soups)

Deli meats & processed meats (e.g., hot dogs, bacon, sausage, pepperoni, lunch meat)

Store-bought baked goods (e.g., packaged cakes, cookies, doughnuts, muffins, store-bought bread)

If any other processed foods, please specify:

Which artificial sweeteners do you consume regularly? (Check all that apply)

Aspartame (e.g., Diet Coke, Diet Pepsi, Equal, sugar-free gum, Crystal Light, sugar-free yogurt)

Sucralose (Splenda) (e.g., protein bars, sugar-free syrups, energy drinks, diet sodas)

Saccharin (Sweet’N Low) (e.g., pink packet sweetener, sugar-free baked goods, some sodas)

Acesulfame K (e.g., flavored waters, protein shakes, pre-packaged coffee drinks)

If any other sweeteners, please specify:

Which High-Fructose Corn Syrup (HFCS) & Processed Sugars do you consume regularly? (Check all that apply)

High-fructose corn syrup (HFCS) (e.g., sodas, candy, commercial bread, fast food, cereals)

Refined white sugar (e.g., packaged sweets, baked goods, flavored yogurts, sauces)

Maltodextrin/Dextrose (e.g., chips, crackers, protein powders, pre-packaged snacks)

If any other processed sugars, please specify:

Which of the following Artificial Food Dyes & Coloring do you consume regularly?

Red 40 (e.g., candy, fruit snacks, sports drinks, chips, maraschino cherries)

Yellow 5 & Yellow 6 (e.g., chips, cereals, cheese-flavored snacks, pickles)

Blue 1 & Blue 2 (e.g., ice pops, sports drinks, candy, sodas)

If any other dyes, please specify:

Which of the following Preservatives & Flavor Enhancers do you consume regularly?

BHA (Butylated Hydroxyanisole) & BHT (Butylated Hydroxytoluene) (e.g., cereals, chips, gum, snack bars, processed meats)

TBHQ (Tertiary Butylhydroquinone) (e.g., frozen foods, crackers, instant noodles, microwave popcorn)

MSG (Monosodium Glutamate) (e.g., fast food, ramen noodles, flavored chips, canned soups)

Sodium Nitrates/Nitrites (e.g., bacon, deli meats, hot dogs, smoked meats)

Carrageenan (e.g., dairy alternatives, store-bought nut milks, cottage cheese, deli meats)

If any other Preservatives & Flavor Enhancers, please specify:

Which of the following Unhealthy Cooking Oils & Fats do you consume regularly?

Vegetable oils (soybean, corn, canola, cottonseed oil, safflower, sunflower oil) (e.g., fried foods, margarine, mayonnaise, salad dressings, fast food)

Hydrogenated or partially hydrogenated oils (trans fats) (e.g., margarine, baked goods, packaged snacks)

Palm oil or palm kernel oil (e.g., peanut butter, protein bars, candy bars, crackers)

If any other Unhealthy Cooking Oils & Fats Enhancers, please specify:

After reviewing these food types, how often do you consume processed or packaged foods?

Never

Rarely (once a month or less)

Occasionally (a few times per month)

Regularly (a few times per week)

Daily

Would You Like Guidance on Reducing Processed Food Consumption & Choosing Healthier Alternatives?

Yes

Cookware, Food Storage & Serving Toxins

Which Types of Cookware Do You Use Regularly? (Check all that apply)

Non-stick cookware (Teflon, PFOA/PFAS coatings) (e.g., T-fal, Calphalon, Rachael Ray, GreenPan, Cuisinart non-stick)

Aluminum cookware or foil (e.g., disposable foil trays, aluminum pans, foil-wrapped baked potatoes)

Stainless steel cookware (e.g., All-Clad, Cuisinart, Tramontina, Made In)

Cast iron cookware (e.g., Lodge, Le Creuset, Staub, Victoria, Field Company)

Ceramic or glass cookware (e.g., Pyrex, CorningWare, Xtrema, Caraway, GreenLife)

If any other type of cookware, please specify:

Do You Heat Food in Plastic Containers?

Yes, regularly (e.g., plastic Tupperware, takeout containers, frozen meal trays, plastic wrap)

Sometimes

No, I dont own plastic containers

What Types of Food Storage & Packaging Do You Use? (Check all that apply)

Plastic food storage containers (e.g., Rubbermaid, Ziploc, Glad, takeout containers)

Plastic water bottles (e.g., Dasani, Nestlé, Poland Spring, SmartWater, Evian)

Plastic wrap or plastic cooking bags (e.g., Saran Wrap, Reynolds plastic cooking bags)

Canned foods (BPA-lined or other chemicals in lining) (e.g., Campbell’s soup, Progresso, canned beans, vegetables)

Silicone bakeware or utensils (some contain fillers or additives that can leach into food)

If any other packaging, please specify:

What Types of Utensils & Serving Materials Do You Use? (Check all that apply)

Plastic utensils (single-use or reusable plastic cutlery) (e.g., takeout plastic forks, spoons, knives)

Wooden or bamboo utensils (safer but some contain chemical coatings or glue)

Metal utensils (stainless steel, titanium, or silverware)

If any other utensils materials, please specify:

What Types of Plates, Bowls, & Cups Do You Use? (Check all that apply)

Plastic plates, bowls, or cups (e.g., disposable or reusable plastic dishware)

Styrofoam plates, cups, or takeout containers (polystyrene can leach toxins into food, especially when heated)

Melamine dishware (commonly used in kids' dishes and camping plates; may release formaldehyde)

Glass dishware (BPA-free, lead-free) (e.g., Pyrex, Duralex, Libbey, Anchor Hocking)

Ceramic dishware (lead-free, non-toxic glaze) (e.g., Xtrema, Our Place, Made In)

If any other dishware materials, please specify:

Would You Like Guidance on Safer Food Storage, Cookware, & Dishware Alternatives?

Yes

Clothing & Textile Toxin Exposure Assessment

Do You Regularly Wear or Use Any of the Following Potentially Toxic Fabrics? (Check all that apply)

Polyester, Acrylic, or Nylon Clothing (synthetic fabrics that shed microplastics and may contain PFAS)

Rayon (Viscose, Modal, Bamboo Fabric that isn’t mechanically processed) (often chemically treated with carbon disulfide, linked to neurotoxicity)

Conventional Cotton (Non-Organic) (treated with pesticides, synthetic dyes, and formaldehyde finishes)

Fast Fashion Clothing (cheaply made synthetic materials that often contain formaldehyde, azo dyes, and plastic-based fibers)

Performance or Water-Resistant Fabrics (e.g., raincoats, activewear, yoga pants with PFAS/"forever chemicals")

Treated Fire-Resistant Pajamas & Baby Clothes (contain flame retardants that can disrupt hormones)

If any other potentially toxic fabric, please specify:

Do You Regularly Use Any of the Following Potentially Toxic Home Textiles? (Check all that apply)

Conventional Bedsheets & Pillowcases (treated with wrinkle-resistant chemicals like formaldehyde)

Synthetic Mattresses (Memory Foam, Polyurethane Foam, etc.) (off-gas VOCs, flame retardants, and endocrine disruptors)

Chemical-Treated Upholstery & Furniture Fabrics (sofa, chairs, curtains, drapes with stain-resistant treatments)

Carpets & Rugs (Synthetic Fibers, Non-Organic Wool) (can contain formaldehyde, flame retardants, stain-resistant coatings)

Non-Organic Cotton Towels & Washcloths (often treated with pesticides and fabric softeners)

If any other potentially toxic home textile, please specify:

Are You Regularly Exposed to These Common Fabric & Textile Toxins? (Check all that apply)

Formaldehyde (used in wrinkle-free clothing, sheets, upholstery, and carpets)

Flame Retardants (PBDEs, Brominated Chemicals) (found in pajamas, mattresses, furniture, car seats, and carpets)

PFAS ("Forever Chemicals") (found in water-resistant, stain-proof, or non-stick fabrics like raincoats, sportswear, and furniture)

Azo Dyes & Other Toxic Dyes (some fabric dyes release carcinogenic amines and heavy metals)

Pesticides & Herbicides in Non-Organic Cotton (residues of glyphosate and other chemicals remain in fabric)

Microplastics & Nanoparticles from Synthetic Fibers (can be absorbed through the skin or inhaled from dust)

If any other textile toxins, please specify:

Have You Taken Steps to Reduce Your Exposure to Clothing & Textile Toxins?

Yes, I have made changes to reduce fabric-related toxic exposure

No, I have not made changes to reduce fabric-related toxic exposure

What Steps Have You Taken to Reduce Your Exposure to Clothing & Textile Toxins?

I wear organic or natural fiber clothing (e.g., organic cotton, hemp, linen, wool, silk)

I use organic or untreated bedding, towels, and furniture fabrics

I use a VOC-free, toxin-free mattress (e.g., organic latex, wool, cotton-based)

I air out or wash new clothes, sheets, and fabrics before use (to reduce chemical residues)

Yes, I use a HEPA air purifier to remove fabric toxins & microplastics from indoor air

If You Have Taken Any Other Steps to Reduce Your Exposure to Clothing & Textile Toxins, please specify:

Would You Like Guidance on Reducing Textile & Fabric Toxin Exposure?

Yes

Mold Exposure & Environmental Risk Factors

Have You Ever Been Exposed to Mold in Your Home, Workplace, or Environment?

Yes, I currently live/work in a moldy environment (visible mold, musty smell, known water damage)

Yes, I have been exposed to mold in the past (past water damage, previous moldy home/workplace)

No, I have never been knowingly exposed to mold

I am unsure

If you answered "Yes," what type of mold exposure have you experienced? (Check all that apply)

Water damage in home/workplace (past or present water leaks, flooding, burst pipes, roof leaks, plumbing issues)

Visible mold growth (on walls, ceilings, furniture, under sinks, in bathrooms, attics, basements)

Musty or damp smell in home/workplace

Use of a humidifier or live in a humid climate (mold thrives in high humidity)

HVAC, AC, or vents contaminated with mold (mold growth inside heating/cooling systems)

Exposure to moldy foods (e.g., coffee, nuts, grains, dried fruit, cheese)

Have You Ever Had Your Home or Workplace Tested for Mold or Mycotoxins?

Yes, my home or workplace was tested, and mold was found

Yes, my home or workplace was tested, but no mold was found

No, I have never had mold testing done

I am unsure

Do You Experience Any of the Following Symptoms That May Be Related to Mold Exposure? (Check all that apply)

Respiratory issues (chronic congestion, sinus infections, asthma, wheezing, shortness of breath)

Brain fog or cognitive issues (difficulty concentrating, memory loss, confusion, dizziness)

Fatigue & weakness (chronic tiredness, feeling drained even after rest)

Headaches & migraines (persistent or unexplained headaches)

Skin issues (rashes, eczema, hives, unexplained itching or irritation)

Joint pain & muscle aches (stiffness, inflammation, fibromyalgia-like symptoms)

Neurological symptoms (tingling, numbness, tremors, sensitivity to light/noise)

Mood changes (anxiety, depression, irritability, mood swings, increased stress sensitivity)

Digestive issues (bloating, nausea, diarrhea, constipation, leaky gut symptoms)

Frequent infections or weakened immune system (recurrent colds, sinus infections, yeast infections, UTIs)

Chemical & food sensitivities (strong reactions to perfumes, cleaning products, alcohol, caffeine, gluten, dairy, processed foods)

Weight gain or difficulty losing weight (even with diet & exercise)

Excessive thirst & frequent urination (signs of toxic burden)

If any other symptoms related to mold exposure, please specify:

Have You Taken Any Steps to Reduce Mold Exposure?

Yes

What steps have You Taken Any Steps to Reduce Mold Exposure? (Check all that apply)

I have remediated mold in my home/workplace

I use an air purifier with a HEPA filter

I follow a mold detox protocol (binders, antifungals, diet, sauna therapy)

If you have taken any other steps to Reduce Mold Exposure, please specify:

Would You Like Guidance on Mold Detoxification or Mold-Resistant Lifestyle Changes?

Yes

Electromagnetic Field (EMF) & Radiation Exposure Assessment

How Often Are You Exposed to EMFs from Wireless Devices & Electronics? (Check all that apply)

I use a cell phone regularly (held to my ear, carried in my pocket, or near my body)

I sleep near electronic devices (Wi-Fi router, smart meter, Bluetooth devices, or a charging phone)

I use wireless headphones or earbuds (e.g., AirPods, Bluetooth headsets)

I work on a laptop or tablet for extended periods (wireless or plugged-in)

I live in an area with 5G towers, power lines, or near a cell tower

I have a smart home (e.g., Alexa, Ring doorbell, smart thermostat, smart fridge, or other IoT devices)

I use an induction cooktop, smart meter, or electric vehicle charging system

I do not take steps to reduce EMF exposure

If Any Other EMFs, please specify:

Do You Experience Any of the Following Symptoms That May Be Linked to EMF Exposure? (Check all that apply)

Headaches or migraines (worsen after prolonged phone or screen use)

Insomnia or disrupted sleep (trouble falling asleep, waking up frequently)

Tinnitus (ringing in the ears) (without an obvious medical cause)

Anxiety, irritability, or mood swings (heightened emotional sensitivity)

Brain fog or difficulty concentrating (worsening after extended device use)

Fatigue or chronic exhaustion (even with adequate sleep)

Unexplained dizziness or nausea (occurs after long exposure to electronics)

Heart palpitations or abnormal heart rhythms (sudden or unexplained)

Skin sensitivity (tingling, itching, or burning sensation near devices)

If You Experience Any Other Symptoms That May Be Linked to EMF Exposure, please specify:

Do You Take Any Precautions to Reduce EMF Exposure?

Yes

What Precautions do you take to Reduce EMF Exposure, please specify:

I use wired headphones instead of wireless (Bluetooth) earbuds.

I turn off my Wi-Fi router at night or use an Ethernet cable for internet.

I keep my phone in airplane mode when not in use or while sleeping.

I use an EMF-blocking phone case or device shield.

I have removed smart home devices (Alexa, Ring, smart meters, etc.)

I use grounding techniques (barefoot on the earth, grounding sheets/mats).

If you take any other precautions to Reduce EMF Exposure, please specify:

Would You Like Guidance on Reducing EMF Exposure and Improving Environmental Health?

Yes

Detoxification, Environmental Toxin Exposure & Lifestyle Awareness

How Often Are You Exposed to Environmental Toxins? (Check the most accurate response)

Never or Almost Never – I actively avoid environmental toxins and have taken steps to minimize exposure.

Rarely – I try to avoid toxic exposure, but I may occasionally come into contact with some environmental toxins.

Occasionally – I am exposed to toxins a few times per month (e.g., processed foods, air pollution, cleaning chemicals, pesticides).

Regularly – I am exposed to environmental toxins multiple times per week due to work, lifestyle, or food choices.

Daily – I live or work in an environment where I am constantly exposed to toxins (e.g., industrial areas, agricultural work, high pesticide or pollution exposure).

Have You Actively Reduced Your Exposure to Environmental Toxins?

Yes

If yes, which of the following toxin reduction strategies have you implemented? (Check all that apply)

Switched to organic foods (to reduce pesticide exposure)

Use a water filtration system (e.g., Berkey, reverse osmosis, distilled water)

Use air purifiers (to reduce indoor air pollutants)

Avoid non-stick cookware (switched to stainless steel, cast iron, or ceramic)

Avoid plastic food containers (switched to glass or stainless steel storage)

Use natural personal care products (aluminum-free deodorant, fluoride-free toothpaste, non-toxic skincare)

Use non-toxic cleaning products (vinegar, baking soda, essential oils, Seventh Generation, Dr. Bronner’s)

If any other toxin reduction strategies, please specify:

Have You Followed a Detoxification Program to Remove Environmental Toxins from Your System?

Yes

If yes, which detox methods have you used? (Check all that apply)

Sauna therapy (infrared sauna, traditional sauna, steam room)

Heavy metal detox (chelation therapy, binders like activated charcoal, chlorella, cilantro)

Liver support (milk thistle, dandelion root, NAC, glutathione, castor oil packs)

Fasting or intermittent fasting (juice cleanses, water fasting, dry fasting)

Lymphatic drainage & movement (rebounding, dry brushing, massage, gua sha)

Colon cleansing (enemas, colon hydrotherapy, fiber-rich diet)

Hydration & mineral balancing (electrolytes, structured water, spring water)

If any other detox methods, please specify:

Would You Like Guidance on Reducing Environmental Toxins and Detoxification Methods?

Yes

Date

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