Reviews




Book Review

"Our Toxic World"



Current Tips

pg. 1
pg. 2



Remedies
To common
Home Toxins
pg. 1 pg. 2




Pregnancy
Chemical
Exposure's

pg. 1
pg. 2



Teflon?



West Nile Virus
Information
pg.1pg.2pg.3
pg.4
pg.5
pg.6
pg.7



Letter To
Maricopa Doctors
pg.1
pg.2



 
 
 



Pesticide / Chemical Exposure
History Form

 

[FrontPage Save Results Component]



HISTORY FORM
FOR PERSONS HURT FROM PESTICIDES
OR OTHER CHEMICAL EXPOSURES



First Name: Middle: Last Name:

Street Address:

 City, State, Zip

Home phone # : Work Phone # :
Cell Phone # :
age:
E-mail Address:

YOU WERE RELATIVELY OR VERY WELL UNTIL WHEN?   (Specify in what way ill before that date. 
For example: Mild allergies such as asthma til June 2002 and then
I was exposed to ----  and------ this is what happened.)

MOST RECENTLY YOU WERE EXPOSED TO? 

 
FOR HOW LONG?  

 
HOW OFTEN? 
  
HOW EXTENSIVE WAS THE EXPOSURE?
 
DID THE PESTICIDE FOGGING IN YOUR AREA MAKE YOU ILL, IN WHAT WAY?

HOW LONG BEFORE ILL FROM EXPOSURE?  MINUTES?  HOURS?

ILL IN WHAT WAY? (Be very specific - burning throat, numb skin, headache, asthma, metallic
taste in mouth, fatigue, dizzy, problems thinking clearly, etc.)


ANYONE ELSE GET ILL?    (Children, spouse, neighbors)

WHO DID YOU SEE  FOR HELP?  (Doctors- how many?

WHAT DID THEY SAY?

HOW WELL DID THEY DIAGNOSE AND TREAT PROBLEM?

|
DID THEY DO BLOOD TESTS?

ANY BRAIN IMAGES (or other brain tests)?

ANY ALLERGY TESTS?

WHAT WAS THEIR TREATMENT?

DID TREATMENT HELP?

  HOW LONG BEFORE YOU FELT BETTER?
 
HOW MUCH BETTER?    IN WHAT SPECIFIC WAYS?
 

COULD YOU DO WHAT THEY SUGGESTED?    IF NOT, WHY NOT 

HOW ARE YOU NOW WHEN EXPOSED TO WHICH CHEMICALS?
(Fresh asphalt, lawn sprays, cleaning materials, store chemicals, perfume, gasoline,
auto exhaust, gas fumes, new carpet, etc.)  IS YOUR RESPONSE DIFFERENT
THAN BEFORE?
  BE AS SPECIFIC IF POSSIBLE

OF NOT DIAGNOSED CORRECTLY,  HOW WOULD YOU BE NOW?

DO YOU HAVE ANY DIFFICULTY FROM SOY PRODUCTS THAT ARE GENETICALLY ENGINEERED?
ARE YOU WILLING AND ABLE TO GO ON A NATIONAL TV PROGRAM TO TALK ABOUT YOUR ILLNESS?

Additional Information




Submit via www.drrapp.com
Or fax it to 480-659-9500


PRIVACY STATEMENT: We do not share any of your information from this form 
with any other third parties, except that which is necessary to process your order request.
Important Health Legislation

Doris J. Rapp, M.D. 1421 Colvin Blvd. Buffalo, New York 14223
Phone 716-875-0398 Fax 716-875-5399 E-mail drrappmd@aol.com
Dr Rapp.com 2004