This questionnaire was part of a US FDA approved study called an Institutional Review Board to assess
how body burden of mercury is determined, toxicity levels etc. It serves as a warning or alert to clinicians
when patients have scores of ‘yes’ in five or more of the questions. It is recommended that such patients
be referred to dentists with special knowledge of safe mercury amalgam removal and replacement.

1. Have you had sore gums (gingivitis) often over the years?


2. Have you had mental symptoms such as confusion or forgetfulness?


3. Has severe depression been a frequent problem?


4. Has ringing in the ears (tinnitus) been present?


5. Have TMJ (temporal mandibular joint) problems been a concern of yours?


6. Have you had unusual shakiness (tremors) of your hands or arms or twitching of other muscles?


7. Do you have “brown spots” or “age spots” under your eyes or elsewhere in the skin of your body?


8. Have you tended to have more colds, flu, and other examples of infectious diseases than “normal”?


9. Have you had food allergies or intolerances?


10. Have you been to many doctors for your health problems and they have usually said, “There is nothing wrong”?


11. Do you have numbness or burning sensations in your mouth or gums?


12. Do you have numbness or unexplained tingling in your arms or legs?


13. Have you developed difficulty in walking (ataxia) over the years?


14. Do you have 10 or more “silver” fillings?


15. Do you often have a “metallic” taste in your mouth?


16. Have you ever worked as a painter or in manufacturing/chemical or pesticide/fungicide factories (fungicides with methyl mercury ingredients) or in pulp/paper mills that used mercury?


17. Have you worked as a dentist, hygienist, or dental assistant?


18. Have you ever had Candida-Related Complex (CRC) or yeast infections (vagina, mouth, or GI tract)?


19. Do you have a lot of bad breath (halitosis) or white tongue (thrush)?


20. Have you frequently had low basal body axillary temperature (below 97.4 degrees F) over the years?


21. Do you have problems with constipation?


22. Do you have heart irregularities or rapid pulse (tachycardia)?


23. Do you have unexplained arthritis in various joints?


24. Is it common for you to have a lot of mucus in your stools?


25. Do you have unidentified chest pains even after EDGs, X-ray and heart studies are normal?


26. Is your sleep poor or do you have frequent insomnia?


27. Have you had frequent kidney infections or do you have significant kidney problems?


28. Are you extremely fatigued much of the time and never seem to have enough energy?


29. Do you have irritability or dramatic changes in behavior?


30. Are you on antidepressants now or have you been in the past?

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