The following questions serve to indicate possiblities of your reactions and sensitivities to substances present in the built environment which may cause varying degrees of Environmental or Building Related Illness. Sustained exposure to molds, mildew, formaldehyde, phenols, fragrances, solvents and elevated electromagnetic fields is known to affect the immune system in some people.... often triggering allergies, psychological effects and poor health. Your answers may not directly prove the existence of Environmental Illness, but it can serve as a starting point to narrow possibilities, avoid the symptoms developing or shed new light on old health problems.

Are you aware of having reactions to (check to indicate yes):___molds___mildew___carpet___pollen

___automobile exhaust fumes___perfumes___laundry detergent___pets___fragrances

___formaldehyde___wood smoke___cigarette smoke___certain foods(if yes, list them)

_______________________________________ ___ printing ink___television sets

___computers___telephone recievers___wool___synthetic fabrics___new furniture

___flourescent light fixtures___incense___scented candles___Others Please describe___________________________

Are there other things not listed here you know you have allergic reactions to? Please list them:

_____________________________________________________________________

Do you have ___depression___anxiety attacks___skin rashes___digestive problems___sneezing

___abdominal cramps___trouble concentrating___problems remembering things

___sudden mood changes___chronic headaches___continuous aching muscles

___chronic low energy___ringing in your ears___alternating clear and fuzzy vision

___constant sinus drainage___painful sinus drainage___acid indegestion ___ recuring sudden

loss of energy___"brain fog"___feelings of despair___wake tired from a full nite's sleep

___itchy palms___burning sensations in your skin___pressure in your skull___migraines

___constant irritability

Have you ever thought or felt that any symptoms you might have are related to a certain building...that is

they only seem to happen when you're in a certain place or environment?________________

Where does that happen?___________________________________________________

Have you ever been diagnosed with ___multiple sclerosis (MS) ___multiple chemical sensitivity(MCS)

___Epstein Barr Virus___attention deficit disorder (ADD)___Asthma___bronchitus

___Chronic Fatigue Disorder(CFDS)___Fibromyalgia___hay fever___irritable bowel syndrome

___food allergies___liver dysfunction___gastro intestinal disorders___EMF sensitivities

___acid reflux___candidiasis___mental/emotional disorders___stress disorders

Have you moved into a new home or remodeled one in the approximate time frame of the onset of any of

these symptoms?___________ If so, when?_____________________________________

Did you change work or school environments in the approximate time frame of any of these disorders?

____If so, please describe the situtation_________________________________________

If you are having what you consider allergic reactions, are they getting ___better or___ worse.

What treatments have you tried?____________________________________________________

______________________________________________________________________

What kinds of medical/ healing help have you tried?______________________________________

______________________________________________________________________

______________________________________________________________________

What have been the results?_______________________________________________________

______________________________________________________________________

______________________________________________________________________

In your belief system, which of the following could be causing health problems___spiritual dilemas

___emotional twists___past life crisis___physical problems___mental problems

___your environment___other people around you___air quality problems___electromagnetic

fields___alcohol___drugs___medications___cancer___unexplained physical illness

Are any of the following found in your living/working environment?___forced air heating system

___air conditioner___new carpet___new paint___fumes___Overhead power lines

___power transformers___computer screens(more than 2 hours per day)___molds

___solvents

Is your bed near:___electric alarm clock or radio___computer___tv___electric hot water heater

___water bed heater___electric service panel___refrigerator___freezer___in-wall electric

radiant heat elements___electric fans/heaters___extension cords___wall outlets

___power cord transformers for answering machines, faxes, etc.

If you have any of the symptoms discussed here, do they go away or lessen if you change living environments, especially after a week or two being somewhere else?__________________

Has anyone ever told you you were crazy or "it's all in your head" if you've broached the possibility

that you illness is being caused you your living environment?_____Who?_______________

If you're having reactions, does it puzzle you that you have them, but others in the same environment

don't?_____Has this happened to you?_______

Do you know, have you heard or read anything about Environmental Illness,Building Related Illness,

or chemical sensitivity?____ Describe that source or contact_________________________

It's very possible that a number of toxins in our envrinments may accumulate to compromise our immune systems and produce multifasceted allergic reactions. Those sources include preservatives, growth hormones, antibiotics and pesticides in our food supply, water born contaminants, air pollution , the off gassing from toxic building products(primarily formaldehyde and phenols) and sensitiving levels of Electro Magnetic radiation from powerlines, transformers, appliances and wiring systems.

The cheapest and most conclusive method of determining if these factors are contributing to any illness you may experience is to learn about them and try moving or eliminating them from your environment and life style. If you symptoms are accute, testing is available to trace EMF sources in your home/workplace, chemical and food allergies and levels of toxins offgasing from building materials.

More difficult to detect are mold and mildew sources...often hidden in crawl spaces, ducting and moist wall interiors. A quick, but often effective way to get a general picture of the health level of your living environment is to find a "Canary"...someone with Environmental Illness who knows what they react to...to do a walk through of your environment and tell you what they find reactive. Not everyone"s reactions are the same, but someone who's sensitized already is a good start as an indicator.

In the long run, unless we reduce the toxins we live with, we may all be headed across the threshold of environmental reactivity and immune disorders in the future.

The Smart Shelter Network can help you find the information and resources you may need if this sounds like something you may be experiencing. We can also help to create a healthier living situation in your new or existing home.