RAYMOND SINGER, PH.D.
A Professional Association
36 Alondra Road / Santa Fe, New Mexico / 87508
Alternate office: 180 E. 79th Street / Suite 1-C / New York, N.Y. / 10021
Telephone: (505) 466-1100 / Fax: (877) 201-3456
Website: www.neurotox.com/ E-mail: firstname.lastname@example.org
Exposure History Questionnaire
Return with a check for $350 for analysis, or visit http://www.neurotox.com/products.php for payment options. Copyright 1998 - 2015, Raymond Singer, Ph.D.. All Rights Reserved.
Your name:_____________________________________ Date___________________
Your telephone number:
Your e-mail address:
Please answer these questions so that Dr. Singer will have a better understanding of your case. Include as many details as you can remember.
It is preferable to return your answers by e-mail, or on a CD or DVD. Otherwise, either use a typewriter of hand write very carefully so that I can easily read what you write. You can use a separate sheet of paper to complete your answers.
1.0 From whom or from what source did you first hear of Dr. Singer?
1.1 Who referred you to Dr. Singer?
1.2 Briefly (1-2 sentences) state why you are consulting Dr. Singer:
2.3 Date of birth:
2.8 Highest grade completed in school:
2.82 Do you have any allergies? Please name them if so.
2.9 Marital status (circle one): Married, divorced, single, separated, widowed, other:_______
2.91 If married, how many years?
2.10 Number of divorces:
2.11 Number of children:
2.12 Names and ages of children:
3.0 What were your symptoms during your initial chemical exposure(s)?
3.1 What were your symptoms the first few days after the exposure(s)?
3.2 Did you consult any doctors or medical experts such as a Poison Control Center immediately after being exposed? If you did not seek out any medical help immediately after your exposure, please explain why.
3.3 Did these medical experts make any notes about your symptoms, give a diagnosis or say that your illness was related with your exposure?
3.6 Was any one else exposed to the same product or chemical? Did they get sick? Include any family members, pets, co-workers, visitors, etc.
3.7 What are your main symptoms now?
3.8 Since your exposure or injury, have you experienced changes to your sleeping habits? If so, describe them.
3.9 Since your exposure or injury, have you experienced changes to your appetite? If so, describe
3.10 Since your exposure or injury, have you experienced changes to your bowel movements? If so, describe them.
3.11 Since your exposure or injury, have you experienced changes to your urination? If so, describe the changes.
4.0 What product or chemical(s) were you exposed to? If possible, give exact product or chemical names. If you do not know the names of the chemicals, describe how they were used. (Example: bug spray used on shrubbery at work during the summer.)
4.1 How were you exposed to these chemicals? For example, were you sprayed with something? Did you drink it? Did you breathe it and touch it? Etc.
4.2 When were you exposed? Try to give exact dates.
4.3 How long were you exposed? Examples: "I worked in an office building from June, 1991 until January, 1993 for eight hours a day, five days per week;" or, "I wore pesticide-soaked clothing for two hours on September 17, 1996." If there was more than one exposure, give specific dates, lengths of time, and list them in order from oldest to most recent.
5.0 Has your home ever been treated for termites or roaches? Provide dates and describe what was done.
6.0 Have you ever been diagnosed with a psychiatric disorder?
6.1 Have you ever sustained a head injury or other serious injury? Did you lose consciousness or experience any memory loss?
6.2 Prior to your injury or chemical exposure, did you have any troubling health problems? If so, describe them.
7.0 In the past, have you ever completed or participated in a neuropsychological examination?
8.0 Prior to your injury or chemical exposure, were you employed?
8.1 What were your job duties?
8.2 Did you complete any special training to perform these duties?
8.3 Prior to your injury or chemical exposure, were you satisfied with your employment?
8.4 Describe any plans you were making to change jobs or improve you job.
8.5 Prior to your injury or chemical exposure, what was your annual income?
8.6 Did you have any financial problems before your injury or chemical exposure? If so, please briefly describe them.
8.7 Have you ever served in the military? If so, provide the dates, locations, rank, and duties you performed. Provide all military medical and performance records including any standardized test results.
9.0 Are you currently employed? Has your employment changed since your injury or chemical exposure? If so, describe the changes.
9.1 Are you satisfied with your current employment situation? Please describe any work-related changes you are planning to make.
9.2 What is your current annual income? Has it changed as a result of your injury or exposure?
9.3 Are your finances currently in order? Have you experienced any financial problems? If so, describe them.
10.0 What schools or colleges have you attended? Include dates, diplomas, certificates, awards, licenses, or degrees earned.
10.1 What was your GPA? Your class rank, if you know?
10.2 What were your best subjects in school?
What subjects were the most difficult?
10.3 Are you currently involved in any educational programs? Have there been any changes since your injury or chemical exposure?
11.0 Prior to your injury or chemical exposure, what were your typical daily activities?
11.1 Prior to your injury or chemical exposure, what types of hobbies or activities did you do and how often? For example: needlepoint every evening; aerobics three times per week; hunting once a month.
11.2 Prior to your injury or chemical exposure, what types of things did you read either at work or at home? How often did you read? For example: read technical chemistry articles three hours per week at work; read entire newspaper daily; read two novels per month.
11.3 Prior to your injury or chemical exposure, what types of social activities did you participate in?
11.4 Describe your relationships prior to your injury or chemical exposure with the following people: your spouse/significant other; your children; your parents; any other family members; and your friends.
11.5 Prior to your injury or chemical exposure, what were your typical activities with your friends?
12.0 What are your current typical daily activities?
12.01 Have your current typical daily activities changed because of your injury or exposure?
What activities and hobbies are you currently involved in?
12.11 If you have given up any hobbies, explain why.
12.2 Describe your current reading habits and any changes since your injury or exposure.
12.3 What types of social activities do you currently enjoy and how often do you do them?
12.4 Describe your current relationships with the following people: your spouse/significant other; your children; your parents; any other family; your friends.
12.5 What are your typical current activities with your friends? Have there been any changes since your injury or exposure?
13.0 Describe your alcohol drinking pattern before your injury or chemical exposure.
13.1 Describe your alcohol drinking pattern since your injury or exposure. If there has been a change, explain why if you can.
14.0 List all of your current medications and nutritional supplements including the dosage and frequency, the doctor who prescribed the medication, and the reason you are taking it.
15.0 Describe the impact your injury or chemical exposure has had on your life. How has it affected you emotionally, physically, spiritually, or in any other way you can describe.
15.1 If there is anything related to the history of your illness that you would like to add, please feel free to do so.
16.0 Did anyone help you answer these questions? If so, who? What sort of help did they provide?