Environmental Health Questionnaire by NAEM

Environmental Health Questionnaire by NAEM

Understanding your lifetime environmental exposures is crucial for identifying potential sources of toxicity and environmental illness. This comprehensive timeline questionnaire helps you document your exposure history to chemicals, mold, heavy metals, and other environmental toxins.

At Nourish Medical Center, we use this detailed environmental history as part of our assessment for patients with suspected environmental illness. This timeline helps identify patterns and potential sources of toxic exposure that may be contributing to your symptoms.

You’ll Learn:

• How to document your environmental exposure history
• Key exposures and time periods to consider
• How this information guides diagnosis and treatment

This handout includes a structured questionnaire covering your residential history (water damage, renovations, proximity to industrial sites), occupational exposures, hobbies and activities that may involve toxins, dental history (amalgam fillings), major illnesses or symptom onset, and timeline of living situations. You’ll create a comprehensive picture of your environmental exposure history.

Who This Handout Is For:

• Individuals with suspected environmental illness
• Patients with unexplained chronic symptoms
• Anyone working with a provider on environmental medicine
• Those with known toxic exposures seeking to document history

Download this handout to create a comprehensive environmental exposure timeline.