randolph environmental questionaire
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Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD Name __________________________ Age _____ Sex _____ Date __________ circle or fill in the following: Marital status: single married living together widowed separated divorced Highest school year: 6 7 8 9 10 11 12 college 1 2 3 4 graduate Occupation _______________ Work Address ______________________________________ Work region: city suburban small town rural Distance from work ________ Travel by: car train bus bicycle walk Home Address _______________________________________________________ Home type: single home duplex apartment hotel trailer floor (if multiple dwelling) ____ How long have you lived there? _________ Region: city residential city industrial suburban small town rural If there is a garage: separate building with inside passage to house in basement of house Heating and ventilation of home Type: electric, heat pump electric, radiant hot water/steam warm air space heater fireplace Fuel: electric gas oil coal wood other ________ Furnace location: basement main floor open utility room closed utility room Air conditioning: window units central system Filters: oiled unoiled electrostatic activated carbon Kitchen exhaust: fan door (Is door usually left open or closed) Utilities Range: electric gas oil age_____ Refrigerator: electric gas age_____ Deep freeze: electric gas age _____ Water heater: electric gas part of furnace Food storage: glass enamel ware plastic Clothes dryer: electric gas age ______ age ______ Furnishings and Household Maintenance Upholstery coverings: cotton linen silk wood synthetic fabrics plastic padding: cotton hair rubber synthetic other_______ Mattresses: cotton rubber wool plastic covered other ____________ Pillows: feather rubber dacron plastic covered foam other ___________ Rugs: wool cotton synthetic natural fiber other ________________ backing: rubber plastic pads: plastic rubber hair 1: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD Curtains: cotton silk wood linen plastic synthetic fabric Cleansers: soap detergents scouring powder bleach ammonia other ___________ Disinfectants: lysol pine-sol air-wick Laundry soap: detergents bleach ammonia Personal Currently used toothpaste: Currently used mouthwash: Currently used cosmetics (name brands, if possible): Deodorant: Shampoo: Soap: Sunscreen: Foundation cream: Lipstick: Eye Shadow: Eye pencil: Hair color: Hair Product: After shave: Body powder: Douche: Contraceptive: Other: Hair Conditioner: Hand Lotion: Mascara: Nail Polish: Shaving Cream: Perfume/cologne: Miscellaneous Insect control: sprays moth balls exterminators Drinking water: tap spring or well chlorinated fluoridated Sense of smell: acute normal poor absent Ability to detect leaking gas: acute normal poor absent When wind is blowing from an industrial area symptoms are: increased unchanged What is your reaction to the following: Coal, oil, gas and combustion products Massive outdoor exposure to coal smoke Smoke in steam railroad stations, train sheds, and yards Smoke from coal burning stoves or furnaces Odors of natural gas fields Odors of escaping utility gas Odors of burning utility gas Odors of gasoline Garage fumes and odors Automotive or motor boat exhaust Odor of naphtha, cleaning fluids, or lighter fluids Odor of recently cleaned clothing, upholstery, or rugs Odor of naphtha containing soaps Odor of nail polish or nail polish remover Odor of brass, metal, or shoe polishes Odor of fresh newspaper Odor of kerosene like _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ neutral _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ dislike made sick from _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 2: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD like neutral dislike made sick from Odor of kerosene or oil burning lamps or stoves _____ Odor of kerosene or oil burning space heaters or furnaces_____ Diesel engine fumes from trains, buses, trucks, or boats _____ Lubricating greases or crude oil _____ Fumes from automobiles burning oil _____ Fumes from burning greasy rags _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Mineral oil, Vaseline, waxes, and combustion products Mineral oil as contained in hand lotions and medications _____ Mineral oil as a laxative _____ Cold cream of face or foundation cream _____ Vaseline, petroleum jelly, or petrolatum ointments _____ Odors of floor, furniture, or bowling alley wax _____ Odors of glass wax or similar glass cleaners _____ Fumes from burning wax candles _____ Odors from dry garbage incinerators _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Asphalts, Tars Resins, and Dyes Fumes from tarring roofs and roads Asphalt pavements in hot weather Tar-containing soaps, shampoos, ointments Odors of inks, carbon paper, typewriter ribbons Dyes in clothing and shoes Dyes in cosmetics (lipstick, mascara, blush, etc.) _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Disinfectants, Deodorants, and Detergents Odor of public or household disinfectants or deodorants _____ Odor of phenol or lysol _____ Phenol-containing lotions or ointments _____ Injectable materials containing phenol as a preservative _____ Fumes from burning creosote-treated wood (railroad ties)_____ Household detergents _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Rubber Odor of or contact with rubber-gloves Contact with elastic in clothes, bras, etc. Odor of sponge rubber bedding, pillows, rug pads Odor of rubber based paint Odor of rubber tires, automotive stores Odor of rubber-backed rugs and carpets Fumes of burning rubber _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 3: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD like neutral dislike made sick from Plastics, Synthetic textiles, Finishes, and Adhesives Odor of or contact with plastic upholstery, table cloths, book covers, pillow covers, shoe bags, hand bags _____ Odor of plastic folding doors or interiors of automobiles _____ Odor of or contact with plastic glasses frames, dentures _____ Odor of plastic products in stores _____ Nylon stockings and other nylon apparel _____ Dacron or Orlon clothing or upholstery _____ Rayon or acetate clothing or upholstery _____ Odor of or contact with adhesive tape _____ Odor of plastic cements _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Alcohol, Glycols, Aldehydes, Esters and Derived Substances Odor of rubbing alcohol _____ Alcohols or glycols as contained in medications _____ Odor of varnish, lacquer, or shellac _____ Odor of after-shave, hair tonics, or hair oils _____ Odor of window cleaning fluids _____ Odor of paint or varnish thinned with mineral solvents _____ Odor of banana oil _____ Odor of scented soap and shampoo _____ Odor of perfumes and colognes _____ Odor of hair spray _____ Fumes from burning incense _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Miscellaneous Air conditioning Ammonia fumes Odor of moth balls Odor of insect repellant candles Odor of termite extermination treatment Odor of DEET containing insecticide sprays Odors of Chlordane, Lindane, Parathione, Dieldrin and other insecticide sprays Odor of the fruit and vegetable sections of markets Odor of chlorinated water Drinking of chlorinated water Fumes of chlorine gas Odor of Chlorox and other hypochlorite bleaches Fumes from sulfur processing plants Fumes of sulfur dioxide 4: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD like Pine Odor of Christmas trees & other indoor evergreen decorations _____ Odor of knotty pine interiors _____ Odor from sanding or working with pine or cedar woods _____ Odor of cedar scented furniture polish _____ Odor of pine scented household deodorants _____ Odor of pine scented bath oils, shampoos, or soaps _____ Odor of turpentine o turpentine-containing paints _____ Fumes from burning pine cones or wood _____ neutral dislike made sick from _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Circle Drugs to which You Suspect You are Sensitive Pain medication: aspirin tylenol ibuprofin motrin demerol vicodin morphine Anesthetics: lidocaine (local) novocaine general other _____________ Antibiotics: penicillin tetracycline sulfa other _____________ Hormones: androgens estrogens progesterone thyroid epinephrine prednisone Anticoagulants Anticonvulsants Headache remedies Laxatives Opiates Sedatives Phenobarbital Tranquilizers Vaccines Vitamins Saccharine Aspartame (NutraSweet) Antihistamines Antispasmodics Asthma remedies Diuretics Barbiturates Codeine Iodides Other: Circle Food Suspected 1. apple cherry peach apricot nectarine pear plum olive currant persimmon 2. strawberry cranberry raspberry blueberry boysenberry pineapple rhubarb 3. grape orange grapefruit lemon tangerine 4. brussel sprouts broccoli cauliflower cabbage head lettuce tomato celery asparagus spinach beet greens chard mustard greens endive escarole 5. leaf lettuce romaine bok choy artichoke 6. lamb beef pork chicken turkey duck 7. Dates figs shelled nuts raisins prunes other dried fruit wheat corn rye barley rice oats dried peas dried beans lentils 8. white flour 9. peach apricot nectarine fresh apple fresh apricot fresh peach French fries molasses dried fruit melon citrus candied peel fruit marmalade dried apple dried pear dried peach dried apricot raisin prune corn syrup corn sugar corn starch corn oil 5: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD 10. crème de menthe maraschino cherries jell-o mint sauce ice cream sherbet hard candy frostings and fillings of pies and cakes hot dogs bologna cheese butter margarine orange sweet potato Irish potato root beer cola other soda pop 11. saccharine NutraSweet 12. banana orange apple pear coffee cane sugar beet sugar 13. carrot parsnip turnip tomato mixed shredded green citrus fruit 14. rutabaga parsnip turnip green pepper apple orange grapefruit tangerine lemon cucumber eggplant 15. coconut 16. turkey chicken duck eggs beef lamb pork fish 17. chlorinated drinking water fluoridated drinking water chlorinated and fluorinated drinking water Do you smoke cigarettes ___________ pipe__________ cigars ____________ Number of smokes per day _____ Age you started to smoke ______ Age you last quit smoking _______ Was is difficult to stop? ___________________ What is your maximum weight? ____________ What is your ideal weight? _____________ Your present weight? _______________ 6: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD Some of the Indoor Chemicals Incriminated in Aggravating Symptoms and Some Therapeutic Measures to Alleviate the Symptoms Fuels -- natural gas, coal, heating oil, stove oil, kerosene, wood For fuel and cooking use electric heat Avoid hydrocarbons Disconnect and remove gas appliances from house Remove all paints and plastics from heating units Alcohols -- rubbing (isopropyl), wood alcohol, ethyl, methyl, spray propellants from some astringents, deodorants, paraffins for canning, depilatories, box coatings Avoid fresh paint, varnish, and stains Paint must be non-odorous No rubber based paints Casein paints are best Avoid flavoring extracts Turpentine and Derivatives from Pine Resins -paints, paint solvents, cedar chests, odor from Christmas trees, pine-scented household cleaners and fresheners Gasoline and Solvents -- Lighter fluids, propane, butane, cleaning fluids, ink, ink solvents, marking- pen inks, adhesives (glue, tape, bandages), naphtha, benzene, solvents in detergents, bleach Plastics -- Toys, plastic bags, vinyl, storage containers, electric-insulating material (heating pads, electric blankets), telephones, television sets, Teflon coatings, shower curtains, eye wear Synthetic Fibers -- Nylon, Acrilan, Dacron, polyester, rayon, darnel, polyurethane Sponge Rubber -- pillows, mattresses, upholstery, rug pads, seat cushions Pesticides -- All insecticides in solid, crystal, or spray form, mothballs, moth-proof clothing, dry cleaning, fumigating agents, fungicides in rubber products Aerate Newspapers and magazines before reading Avoid use of detergents and bleaches Use unscented soaps Avoid or replace adhesive in flooring The more odorous and flexible the plastic, the more likely to cause symptoms Allow aeration of plastic products must use Have good ventilation when TV is in use Use glass or enamel storage and cooking containers Wear few synthetic clothing Untreated cotton or undyed wool is best Do not wear synthetics next to body Use feather pillows or cotton bundles Avoid rug shampoos that contain DDT Avoid moth proofing blankets often Aerate clothing after dry cleaning 7: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd Clinical Medicine Human Ecology and Susceptibility to the Chemical Environment Questionnaire Theron G. Randolph, MD Miscellaneous -- chlorine, ammonia, phenols, creosols, camphor, menthol, any smoke from a natural compound (tobacco, marijuana, burnt food), perfumes, colognes, scented soaps, cosmetics and sprays, contraceptives (gels, creams, foams), shaving lotion, fabric-treating agents (waterrepellent coatings and sprays on outdoor equipment) Avoid tobacco products Avoid phenols and other chemicals in wallpaper paste Purchase natural-based paste Use baking soda instead of silver and brass polish 8: human ecology & susceptibility to the human environment by Randolph/eric jones nd dr.j/nd
