mercury
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


   ___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
   ___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.
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erich a wolley dds

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