Non-Patient Record Review - Beck Natural Medicine University

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List sympLoms you knorv or suspcct (that are madc rvorse) from exposurc toLakesidcCountrysideAnimals. barn. havSpring, summer or fallDust or moldFoodsWork or schoolWood stove smokeCigarette smokePaintAir conditioningPollensLau,n morvingDampncssCold rveathcrHot rveatherWeather chansesPerfumeVCcsmeticsPolishes/CleansersFabric softenerDetergentsBeing overtiredCertain storesPlasticsCooking odorsSmokeFabricsChemicals (specify)FumesOdorsPaperNewsprintCertain buildingVMallsCleaning suppliesTraffuc exhaustParking garagesChristmas treesChalkWoolMenstrual preriodsOthcrsSymotomsCheck Applicable OneKno'rv SuspeclKnou, SuspectKnow SuspcctKnow SuspcctKnou' SuspcctKno'rv SuspectKnorv SuspcctKlorv SuspectKnorv SuspcctKnow SuspectKnorv SuspectKnorv SuspectKnorv SuspcctKnorv SuspeciKrorv SuspectKnorv SuspectKnorv SuspectKnow SuspectKnorv SuspectKnow SuspectKnow SuspectKnorv SuspectKnow SuspectKnow SuspectKnow SuspectKnow SuspectKnow SuspectKnow SuspectKnow SusgrctKnow SuspectKnow SuspectKnorv SuspectKnorv SuspectKnorv SuspectKnorv SuspectKnorv SuspectKnou, SuspectKnorv SuspectKnorv SuspcctKnorv _Knorr,_SuspcctSusp:c'-
When were you last well?Within two years of thc onset of your symptoms, drd you do any of the following.Change Jobs?Renovate your olTicc or home?Move to a new officc or home?Panel any rooms?Insulate any rooms?Carpet any rooms?Buy nerv furniture or bed?Install drop ceilings?Paint indoon?Sidc the housc?Change your heating system, stove- clothes drycr,or water heater?Used antibiotics?Used pesticide indoors or out?Have dental work done (fillings. root canals, etc)?Have emotional distrcss?YcsYesYesYesYesYesYcsYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoCheck OneNcve rNcvcrNcverNevcrNeve rNeverNeverNcvcrNeverNeve rNeverNcverNevcrNevcrNcvcrDo you have any gas utilities?Do you use alcohol?Do you use cigarettes?Do you drink coffee?Do you drink tea?Do you drink soft drinks?Do you pesticide your lawn or household plants?Do you wear numy dry+leaned clothes?Do you wear nnny polyester clothes?Do you we:tr many pennanent press clothes?Have you ever lived in a pesticided home?Have you ever lived in a urea foam formaldehydeinsulated (JIFI) home?Have you ever lived in a brand nerv home?Have you ever worked in a nerv office?YesYesYesYesYesYesYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoNoNoNo-NoNoNeverNo,crNcverNeverNeverNeverNeverNeverNcverNeverNeverNeverNeverNeverlf your symptoms have been present all your life, rvhat lvorsens or provokes new symptoms?Give brand names (if able) for any of the following that you use:BlushFoundationLipstickMascaraHair conditionerShampooHairsprayAfter shavcDeodorantFabric softcnerSoapOthcr toiletrics
Page 3 and 4: Slmptoms thalbother YouAllyear?Yes
Page 9 and 10: At any time in your life were you e

Non-Patient Record Review - Beck Natural Medicine University

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