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Cary, NC 27518, USA | Directions
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Mercury toxicity

 Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.

*Last name :
*First name :
M.I :
1.Do you have mercury / silver fillings? YesNo
2.Have any of your mercury / silver fillings been replaced? YesNo
3.Were your fillings removed using a rubber dam? YesNo
4.Did you have mercury / silver fillings in your baby teeth?YesNo
5.Did you have all of your childhood vaccines? YesNo
6.Where did you grow up? (City / State)
7.Were you on or near farms? YesNo
8. Were you near large industry? YesNo
9.What are all the jobs you have held? (List)
10.What hobbies have you done with paints or other chemicals / liquids?
11.Have you ever siphoned gasoline with your mouth or washed your hands in gasoline? YesNo
12.Did you ever play or work in apple, peach, citrus or other orchards? YesNo
13.Where you ever diagnosed with mercury or heavy metal toxicity?YesNo
14.How was the diagnosis made?
Are there lab reports? (please provide copy) YesNo
15.Have you been doing any detoxification? YesNo
16.What was the reason that you ended up with the diagnosis of heavy metal toxicity?
Do you have a diagnosed disease or disability thought to be related? YesNo
17.Who diagnosed your disease now thought to be related to heavy metal toxicity?
Are you still seeing that provider? YesNo
Are they supportive of alternative care? YesNo
Do they know you are here? YesNo
18.Who else do you see besides the provider who sent you here (if referred)? Please list
19.What are your beliefs or understandings about heavy metal toxicity?
20.What are your goals for being here?
*Signature of Responsible Party
Date