Summary Health and Environmental History

The Summary Health and Environmental History form is intended to help all doctors identify chemical injury and sensitivity potential within minutes. Below is an explanation of each question on the summary history.

Question 1: People with burning-like sensations often have irritant/chemical related health problems, rather than allergies. Allergies do not cause burning sensation but rather sneezing, itchy watery eyes, etc.

Question 2: The average healthy person should have no or only slight symptoms with four hours of exposures described in Question 2. Individuals who checked moderately or a lot demonstrate intolerance to chemicals with four hours exposure. Any increase in symptoms with 20 minutes of exposure is abnormal.  This question was able to distinguish between healthy individuals and persons with chemical sensitivity in research conducted at Johns Hopkins.

Question 3: Based on the experience of Dr. Ziem with thousands of patients with chemical injury, the particular symptoms listed in Question 3 are the most common suffered by persons with chemical injury.  Other conditions can cause these symptoms but when they occur together with abnormal responses on Questions 1 or 2 above, chemical sensitivity/injury/exacerbation is likely.  In small children frequent ear infections are more common sinus symptoms.  Question 3 also uses identical wording which was found to be valid in research conducted at Johns Hopkins.

Questions 4 through 8: Questions 4 through 8 are self-explanatory.

Question 9: This question is intended to help a doctor take an exposure history. This clarifies when the exposure began and ended. It includes only frequent or heavy exposures likely to initiate chemical illness. The X is very important because exposures that caused symptoms with or shortly following exposure in individuals who were previously healthy may well have contributed to causation of a toxic-related problem.

Question 10: This is to help the doctor identify things which may exacerbate symptoms in someone who has chemical injury or who has other respiratory or chronic inflammation. All Yes answers are a potential problem, worse for those who are already ill.

Any mold/mildew in the home is a risk but should be addressed in a nontoxic manner. For more information about how patients can reduce hazards, refer them to the excellent reference Less Toxic Alternatives, by educator Carolyn Gorman to (800-428-2343).

Questions 12 and 13: Questions 12 and 13 are important because spending time in a nontoxic outdoor area on a frequent basis is important for maintaining good health.

The wording in some of the questions has been validated by research (Questions 2 and 3) and others have been used for evaluation of hundreds of patients. It is suggested that the physician try the format wording suggested in Questions 1 to 13 before changing the wording. This is because changing wording in questions can greatly change the response.

Any suggestions for improving the questionnaire and experience describing its usefulness can be addressed in writing to Dr. Ziem: Dr. Grace Ziem, M.D., P.H., 16926 Eyler’s Valley Rd., Emmitsburg, MD 21727

Download the Summary Health and Environmental History here.

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