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Dental Care & Wellness of Sonoma County

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Mercury/Toxic Metal Sensitivity Questionnaire

This questionnaire was part of a US FDA approved study called an Institutional Review Board to assess how body burden of mercury is determined, toxicity levels etc. It serves as a warming or alert to clinicians when patients have scores of 'Yes' in five or more of the questions. It is recommended that such a patients be referred to dentists with special knowledge of safe mercury amalgam removal and replacement.
1. Have you had sore gums (gingivitis) often over the years? Yes No
2. Have you had metal symptoms such as confusion or forgetfulness? Yes No
3. Has severe depression been a frequent problem? Yes No
4. Has ringing in the ears (tinnitus) been present? Yes No
5. Have TMJ (temporal mandibular joint) problems been a concern of yours? Yes No
6. Have you had unusual shakiness (tremors) of your hands or arms or twitching of other muscles? Yes No
7. Do you have "brown spots" or "age spots" under your eyes or elsewhere in the skin of your body? Yes No
8. Have you tended to have more colds, flu, and other examples of infectious diseases than "normal"? Yes No
9. Have you had food allergies or intolerances? Yes No
10. Have you been to many doctors for your health problems and they have usually said, "There is nothing wrong"? Yes No
11. Do you have numbness or burning sensations in your mouth or gums? Yes No
12. Do you have numbness or unexplained tingling in your arms or legs? Yes No
13. Have you developed difficulty in walking (ataxia) over the years? Yes No
14. Do you have 10 or more "silver" fillings? Yes No
15. Do you often have a "metallic" taste in your mouth? Yes No
16. Have you ever worked as a painter or in manufacturing/chemical or pesticide/fungicide factories (fungicides with methyl mercury ingredients) or in pulp/paper mills that used mercury? Yes No
17. Have you worked as a dentist, hygienist, or dental assistant? Yes No
18. Have you ever had Candida-Related Complex (CRC) or yeast infections (vagina, mouth, or GI tract)? Yes No
19. Do you have a lot of bad breath (halitosis) or white tongue (thrush)? Yes No
20. Have you frequently had low basal body axillary temperature (below 97.4 degrees F) over the years? Yes No
21. Do you have problems with constipation? Yes No
22. Do you have heart irregularities or rapid pulse (tachycardia)? Yes No
23. Do you have unexplained arthritis in various joints? Yes No
24. Is it common for you to have a lot of mucus in your stools? Yes No
25. Do you have unidentified chest pains even after EDGs, X-ray and heart studies are normal? Yes No
26. Is your sleep poor or do you have frequent insomnia? Yes No
27. Have you had frequent kidney infections or do you have significant kidney problems? Yes No
28. Are you extremely fatigued much of the time and never seem to have enough energy? Yes No
29. Do you have irritability or dramatic changes in behavior? Yes No
30. Are you on antidepressants now or have you been in the past? Yes No

(Your digital signature (full name) is as legally binding as a physical signature.)