FOR PERSONS HURT FROM PESTICIDES
OR OTHER CHEMICAL EXPOSURES
Home phone # :
Work Phone # :
Cell Phone # :
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
I was exposed to ---- and------ this is what happened.)
MOST RECENTLY YOU WERE EXPOSED TO?
FOR HOW LONG?
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,
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
ARE YOU WILLING AND ABLE TO GO ON A NATIONAL TV PROGRAM
TO TALK ABOUT YOUR ILLNESS?
fax it to 480-659-9500