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Hair Test Questionairre

Page One

1. Hair Test Number to which this test is linked. See http://livingnetwork.co.za/chelationnetwork/hairtest/ for list of hair tests.

2. Date of birth *This question is required.

calendar

3. Gender *This question is required.

Male
Female

4. Height (please determine accurately and include unit of measurement e.g. 1.58m or 5 foot 6 inches)

5. Weight (please determine accurately and include unit of measure e.g. 70.5kg or 160lbs)

6. Dominant hand function

Right handed
Left Handed
Ambidextrious

7. Place of Birth

8. Residence, last 2 years (State/City/Country)

9. Occupation the last 2 years

10. Prior occupations where exposure to heavy metals might have occurred (welder, lab tech, photo developer, medical or dental assistant, electronics production, chemical applicator, etc.)

11. Significant Past Medical History (please provide all diagnoses offered even if you don't agree with them, as well as anything you think is going on even if not formally diagnosed)

12. Past dental history (type of fillings; gold, amalgams etc. if any, crowns, root canals and note if gum cut open to fill base of root)

13. Usual Diet and preferences

14. Dietary restrictions you observe

15. Fish or Seafood (include type and frequency)

16. Do you have any of the following conditions

Space Cell	Yes	No	Unknown
chronic fatigue	Yes	No	Unknown
fibromyalgia	Yes	No	Unknown
brunescence of the crystallline lens	Yes	No	Unknown
convergence insufficiency (mild)	Yes	No	Unknown
accomodative insufficiency (mild)	Yes	No	Unknown
mydriasis (mild)	Yes	No	Unknown
Have you needed prescription glasses or contacts redone more than once when you got them?	Yes	No	Unknown
Does your distance vision get blurry on occasion?	Yes	No	Unknown
Amblyopia	Yes	No	Unknown
Proptosis	Yes	No	Unknown
crossing changes in the retina	Yes	No	Unknown
abnormally fast or slow respiration at rest	Yes	No	Unknown
dry skin	Yes	No	Unknown
unusually dry skin	Yes	No	Unknown
poor balance	Yes	No	Unknown
tics or twitches of facial muscles	Yes	No	Unknown
abnormalities on neurological exam	Yes	No	Unknown
reduced or unusual sensation in hands and feet	Yes	No	Unknown
desquamation or exfoliative dermaitits or hyperkeratosis on hands or feet or ankles	Yes	No	Unknown
redness and peeling of the finger pads on occasion	Yes	No	Unknown
do you sweat less than most people?	Yes	No	Unknown
Women: have you had amenhorreoa more than once?	Yes	No	Unknown
are you tired after a shower?	Yes	No	Unknown
bleeding gums	Yes	No	Unknown
tender teeth	Yes	No	Unknown
metallic taste in mouth	Yes	No	Unknown
blisters or sores in mouth	Yes	No	Unknown
sore or irritated throat	Yes	No	Unknown
loss of appetite	Yes	No	Unknown
headaches	Yes	No	Unknown
inability to concentrate	Yes	No	Unknown
dizziness	Yes	No	Unknown
muscle tremors	Yes	No	Unknown
chest pains	Yes	No	Unknown
allergy (describe in more detail on a separate sheet)	Yes	No	Unknown
bad breath	Yes	No	Unknown
diverticulosis/itis	Yes	No	Unknown
diarrhoea and constipation	Yes	No	Unknown
colic	Yes	No	Unknown
excessive fatigue	Yes	No	Unknown
muscles tire easily	Yes	No	Unknown
sciatic	Yes	No	Unknown
leg cramps	Yes	No	Unknown
joint pains	Yes	No	Unknown
cold hands and feet	Yes	No	Unknown
tachycardia	Yes	No	Unknown
anxiety	Yes	No	Unknown
tension	Yes	No	Unknown
depression	Yes	No	Unknown
forgetfulness	Yes	No	Unknown
shyness	Yes	No	Unknown
being easily embarrassed	Yes	No	Unknown
angina	Yes	No	Unknown
pattern of illness after amalgam placement	Yes	No	Unknown
unusual development or learning issues through age 8	Yes	No	Unknown
Any first degree relative believes they have a mercury problem (regardless of your personal opinion about it)	Yes	No	Unknown
daily volume of urine produced exceeds 2.5 liters on average	Yes	No	Unknown

17. Question for men only: Fingertip to fingertip arm-span (please actually measure it by putting your fingertips in the corner of a room, and stretching your arms out and measuring the distance from the corner to your fingertips) in meters e.g. 1.2m

18. Question for women only:
Age of first menstrual period e.g 13 years 3 months

19. If you happen to have any clinical laboratory testing available on yourself, or remember results, please fill in the following table. Answer yes if any test was abnormal

Space Cell	Yes	No	Unknown
prolonged QT time, T wave flatteng, ST segment depression or sinus tachycardia on EKG.	Yes	No	Unknown
any porphyrin above lab limit in blood or urine or stool	Yes	No	Unknown
elevated venous CO2	Yes	No	Unknown
low venous CO2	Yes	No	Unknown
Women: triglycerides <40	Yes	No	Unknown
Men: triglycerides <50	Yes	No	Unknown
Cholesterol <130	Yes	No	Unknown
low HDL cholesterol	Yes	No	Unknown
cholesterol > 270	Yes	No	Unknown
Men: low serum iron	Yes	No	Unknown
Idiopathic elevated AST	Yes	No	Unknown
Men: ALT more than points above lab limit	Yes	No	Unknown
Women: ALT higher than 8 units BELOW lab upper normal limit	Yes	No	Unknown
2xNa + BUN/2.8 + glucose/18 > 290	Yes	No	Unknown
elevated hematocrit	Yes	No	Unknown
elevated MCV	Yes	No	Unknown
elevated MCH	Yes	No	Unknown
Any low or high thyroid parameter	Yes	No	Unknown
any lab indicator of low cortisol	Yes	No	Unknown
low PRL	Yes	No	Unknown
Low NK cell number, activity, low total T cells, low CD8 cells.	Yes	No	Unknown
IgE > 292 IU	Yes	No	Unknown
Any low immune globulin class or subclass	Yes	No	Unknown
hypoglycemia (even if only your own personal opinion, indicate if so)	Yes	No	Unknown
elevated pyruvate	Yes	No	Unknown
elevated lactate	Yes	No	Unknown

20. Value of serum DHEA-S is:

If you have any laboratory measurements of either urine or red blood cell or hair or stool mineral levels, please supply them if that is possible by emailing surveys@livingnetwork.co.za

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