mercury
questionnaire
questionnaire
1. Heart Problems
___heart/chest pains
___angina
___tachycardia
___heart murmur
___low blood pressure
___abnormal EKG
___endocarditis
___partial heart block
___high blood pressure
___heart attack
2. Skin Problems
___unexplained rashes
___excessive itching
___red flushes of color
___rough skin
___acne (pimples)
3. Nervous Disorders
___Bell's Palsey
___Multiple Sclerosis
___shingles
___epilepsy/convulsions
___Dr told you "it's your nerves"
___hands, feet, or head "shake"
___face or other muscles "twitch"
4. Digestion
___diverticulitis
___ulcers
___Crohn's disease
___Graves disease
___indigestion
___diarrhea
___bloated feeling after eating
___heartburn
___poor appetite
5. Blood Disease
___mononucleosis
___false positive for venereal
disease
___heart/chest pains
___angina
___tachycardia
___heart murmur
___low blood pressure
___abnormal EKG
___endocarditis
___partial heart block
___high blood pressure
___heart attack
2. Skin Problems
___unexplained rashes
___excessive itching
___red flushes of color
___rough skin
___acne (pimples)
3. Nervous Disorders
___Bell's Palsey
___Multiple Sclerosis
___shingles
___epilepsy/convulsions
___Dr told you "it's your nerves"
___hands, feet, or head "shake"
___face or other muscles "twitch"
4. Digestion
___diverticulitis
___ulcers
___Crohn's disease
___Graves disease
___indigestion
___diarrhea
___bloated feeling after eating
___heartburn
___poor appetite
5. Blood Disease
___mononucleosis
___false positive for venereal
disease
___get up at night to urinate
___urinate frequently daytime
___have insomnia
___tired when awake in morning
___trouble making decisions
10. Allergies
___metal
___fabrics
___soaps and detergents
___food
___other___________________
11. Diseases
___rheumatoid
___bursitis
___tennis elbow
___painful joints
___Friedrich's ataxia
___asthma
___surgery ________________
___osteomyelitis
___psoriasis
___sickle cell anemia
___chronic anemia
___kidney stones
12. Miscellaneous
___infections take long time to
heal
___work around mercury?
capacity________________
___medications_____________
13. Dental History
___had silver amalgams
___have silver amalgams
___had gold fillings
___have gold fillings now
___removable metal bridge
___gold bridge
___porcelain caps (crowns)
___non-precious crowns
___root canal
___root canal now
___metallic taste in mouth
___burning sensation in mouth
___increased flow of saliva
___more than half your teeth
6. Cancer___urinate frequently daytime
___have insomnia
___tired when awake in morning
___trouble making decisions
10. Allergies
___metal
___fabrics
___soaps and detergents
___food
___other___________________
11. Diseases
___rheumatoid
___bursitis
___tennis elbow
___painful joints
___Friedrich's ataxia
___asthma
___surgery ________________
___osteomyelitis
___psoriasis
___sickle cell anemia
___chronic anemia
___kidney stones
12. Miscellaneous
___infections take long time to
heal
___work around mercury?
capacity________________
___medications_____________
13. Dental History
___had silver amalgams
___have silver amalgams
___had gold fillings
___have gold fillings now
___removable metal bridge
___gold bridge
___porcelain caps (crowns)
___non-precious crowns
___root canal
___root canal now
___metallic taste in mouth
___burning sensation in mouth
___increased flow of saliva
___more than half your teeth
___leukemia
___Hodgkins disease
___any other name
7. Endocrine Problems
___diabetes
___ovaries
___hysterectomy-complete
___tipped uterus
___overweight
___thyroid overactive
___testes
___pancreas
___cervical erosion
___underweight
___prostate
___menstruation-painful,
too often, or too
seldom, stopping w/o
reason
8. Emotional
___sudden anger
___depression
___wish you were dead
___irritability
___suicidal tendencies
___been divorced
9. Annoying Symptoms
___frequent headaches
___noises in your ears
___ringing in your ears
___hissing in your ears
___chronic eye inflammation
___chronic fatigue
___do you tire easy?
___swollen lymph nodes
___sweat excessively
___hearing problems
___cold hands and feet
___motion sickness
___slow healing
___leg cramps
___dizziness
Please check all past or present symptoms which apply to you.
We are most grateful to Dr Hal Huggins for the following Mercury Questionnaire. The questionnaire is reprinted from A Patient's Guide to Mercury Amalgam Toxicity, Dr Roy Kupsinel.
Mercury Questionnaire
Should you decide you would like a copy of Dr Kupsinel's A Patient's Guide to Mercury Amalgam Toxicity contact us.
erich a wolley dds
