1. Heart Problems
   ___heart/chest pains
   ___heart murmur
   ___low blood pressure
   ___abnormal EKG
   ___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
   ___Dr told you "it's your nerves"
   ___hands, feet, or head "shake"
   ___face or other muscles "twitch"

4. Digestion
   ___Crohn's disease
   ___Graves disease
   ___bloated feeling after eating
   ___poor appetite
5. Blood Disease
   ___false positive for venereal

   ___get up at night to urinate
   ___urinate frequently daytime
   ___have insomnia
   ___tired when awake in morning
   ___trouble making decisions

10. Allergies
   ___soaps and detergents

11. Diseases
   ___tennis elbow
   ___painful joints
   ___Friedrich's ataxia
   ___surgery ________________
   ___sickle cell anemia
   ___chronic anemia
   ___kidney stones

12. Miscellaneous
   ___infections take long time to
   ___work around mercury?

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
   ___Hodgkins disease
   ___any other name

7. Endocrine Problems
   ___tipped uterus
   ___thyroid overactive
   ___cervical erosion
          too often, or too
          seldom, stopping w/o

8. Emotional
   ___sudden anger
   ___wish you were dead
   ___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
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