1.
Do you dislike the taste of your tap water or do you feel that it causes
symptoms?
2.
Do you react to wood burning stoves, fireplaces, or kerosene space heaters?
3.
Do you react when entering fabric shops, carpet stores, grocery stores,
or department stores?
4.
Do you react or dislike the odor of perfume, soap, detergents, colognes,
or other solvents, such as fingernail polish remover, paint remover, model
airplane glue, etc.?
5.
Do you dislike or react to disinfectants, insecticides, sprays, ammonia,
or moth balls?
6.
Do you react or dislike the odor of Christmas trees or other indoor evergreen
decorations, odor from sanding or woodworking, odor of a cedar closet,
or pine-scented household deodorants, shampoos, or turpentine based paints?
7.
Do you react to or dislike the odor of exhaust fumes, jet airplane exhausts,
oil, or gas fumes or diesel fumes from trucks and buses?
8.
Do you feel that you react to your working environment, either continuously
or depending upon the area of the workplace that you are in?
9.
Do you have hobbies that involve exposure to smells, odors, chemicals,
paints, ceramics, or dusty moldy, chemically contaminated areas?
10.
Do you have a tendency to have unpleasant feelings or reactions to
all medicines taken by mouth regardless of what condition they are given
for?
11.
Do you take large amounts of over-the-counter medications, such as vitamins,
headache pills, sinus pills, etc.?
12.
Do you react to other people’s use of tobacco (cigarettes, pipes,
cigars)?
13.
Do you react to all types of fresh fruit and vegetables and improve if
the substances are cooked or peeled?
14.
Do you react to foods that are commercially prepared while not reacting
to the same foods that are eaten fresh or prepared at home?
15.
Do you have difficulty eating in restaurants, but are able to eat the
same foods when prepared at home?
16.
Do you feel that you perform or feel better in natural lighting compared
to fluorescent lighting?
17.
Do you react to newsprint or other printed material?