Did you live within 15 miles of agricultural land or farms where DDT or other major pesticides were used during childhood or early adulthood?
*
never
briefly
4-6 years
6-10 years
more than 10 years
Have you ever swum or fished in lakes or rivers known for mercury or PCB contamination?
*
never
rarely
occasionally
more than I would like to think about now!
frequently
Do you know if you were fed formula or milk from plastic bottles?
*
never
rarely
sometimes
frequently
yes, and they were playtex bottles
How often did you or your household use aluminum cookware or bakeware?
*
never/not at all
rarely
sometimes
frequently
often
Have you ever had dental amalgam (“silver”) fillings?
*
never
4 or less removed by a biologic dentist
4 or less still present or removed by my regular dentist
more than 4 removed by a biologic dentist
more than 4 still present or removed by my regular dentist
Did you live in a home during the 1960s–80s with lead-based paint or pipes?
*
no
not sure
briefly
most of my childhood
currently live in an old home with old pipes
Did you or do you use Kohl Pencil eyeliner?
*
never
rarely
I used to but don't now
sometimes
all the time
Did/do you frequently use Teflon-coated (nonstick) cookware?
*
never/not at all
rarely
sometimes
regularily
all of the time
Do you remember “fogging” or spraying for bugs inside or outside the home?
*
never/not at all
not sure
rarely
sometimes
frequently
Have you ever handled receipts, tickets, or paper products regularly (thermal paper contains BPA)?
*
No
Rarely
As a consumer, is there a choice?
I worked in an environment where I used them every day, briefly
I work(ed) with them for an extended period of time
Did you use conventional hair dyes (especially dark colors) or chemical treatments through teenage years or adulthood?
*
never
once or twice
occasionally
frequently
still do
How often have you used or microwaved food in plastic containers?
*
never
rarely
sometimes, in the past
frequently, in the past
still do
Did you use weed killers, bug sprays, or chemical fertilizers in gardening or lawn care?
*
not at all
rarely
sometimes, in the past
frequently, in the past
still do
Have you consumed fish from lakes or oceans known for higher mercury or PCB levels?
*
not at all
rarely
occasionally, in the past
frequently, in the past
still do
Have you ever had your water supply tested for contaminants such as lead or PFOS/PFAS?
*
frequently
I have a good filter (RO with minerals re-added)
I use a charcoal filter
no
Do you frequently experience symptoms like headaches, fatigue, hormone changes, or unexplained rashes?
*
never/not at all
rarely
sometimes
frequently
most of the time
Have you used air fresheners, scented candles, or plug-in fragrances in your home?
*
no
rarely
sometimes
often
no, they make me feel sick
Were you exposed to cigarette smoke or lived with a smoker during childhood?
*
no
rarely
one parent
both parents
so much so, that I used to smoke myself
I still smoke
Do you regularly drink water from plastic bottles or use disposable coffee cups?
*
no
yes, but in the past
occasionally
frequently
