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TOXIC EXPOSURE QUESTIONNAIRE

This brief questionnaire helps identify common sources of toxic burden — from household products to food and air quality — so we can better support your body’s natural detoxification processes.

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Please answer each question honestly. There are no right or wrong responses — this is simply to guide your personalized wellness plan.

Results will be sent to your email

Section 1: Home & Environment

Do you live near high-traffic roads, industrial areas, or farms using pesticides?
Do you notice strong odors (chemical, mold, gas) in your home or workplace?
Have you ever had visible mold or water damage in your home?
How often do you open windows or get fresh air circulation in your home?

4=Never 3=Rarely 2=Sometimes 1=Often 0=Always

Do you use air or water filters?

Section 2: Personal & Household Products

Do you use scented candles, air fresheners, or fabric softeners?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

How often do you use conventional cleaning products or bleach-based disinfectants?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Do you use conventional personal care items (lotions, cosmetics, deodorant, hair products) instead of natural or fragrance-free options?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Do you use non-stick cookware or plastic containers for hot food?

Section 3: Food & Nutrition

How often do you eat non-organic fruits, vegetables, or meats?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Daily

Do you frequently consume processed or fast food?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Daily

Do you regularly consume alcohol?

0=Never 1-Rarely 2=Sometimes 3=Often 4=Always

Have you ever experienced sensitivity or reactions to certain foods or additives?
Do you drink

Section 4: Medical & Occupational Exposures

Have you had frequent dental fillings or amalgam (silver) fillings?
Do you work with chemicals, paints, cleaning agents, or heavy metals?
Have you ever experienced unusual reactions to medications, anesthesia, or vaccines?
Do you smoke tobacco or are you regularly exposed to secondhand smoke?

Section 5: Detox & Elimination

Do you sweat regularly (through exercise or sauna use)?
Do you experience unexplained fatigue, headaches, or skin breakouts?

0=Never 1=Rarely 2=Sometimes 3=Often 4=Always

Do you notice strong body odor or chemical sensitivity (perfume, cleaners)?

Section 6: Reflection

Consent & Acknowledgement

By submitting this form, I acknowledge that the information provided is truthful to the best of my knowledge. I understand that this questionnaire is for wellness and educational purposes only and does not establish a medical provider–patient relationship. I further understand that the results will be reviewed by Dr. Sandra McKenzie for the purpose of offering general wellness guidance or discussing next steps, and that any personalized recommendations will require a formal consultation.

This questionnaire is a screening tool, not a diagnosis.

Results help guide awareness and discussion.

Personalized recommendations require a clinical consultation.

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