Environmental Triggers Intolerance Assessment Form
Assess how various environmental factors may affect your well-being by rating your intolerance or sensitivity to common triggers.
How often do you experience discomfort or symptoms when exposed to pollen?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
How would you rate your sensitivity to dust or dust mites?
*
1
2
3
4
5
How do you typically react to exposure to mold or mildew?
*
No reaction
Mild discomfort
Moderate symptoms
Severe reaction
Rate your intolerance to strong chemical odors (e.g., cleaning products, paint).
*
Not at all
1
2
3
4
Extremely intolerant
5
1 is Not at all, 5 is Extremely intolerant
How sensitive are you to changes in weather (e.g., temperature, humidity, barometric pressure)?
*
1
2
3
4
5
Which of the following pets, if any, trigger symptoms for you? (Select all that apply)
*
Dogs
Cats
Birds
Rodents
None
Other
How often do you experience symptoms when exposed to air pollution or smog?
*
Never
1
2
3
4
Always
5
1 is Never, 5 is Always
Please indicate your reaction to exposure to tobacco smoke or vaping.
*
No reaction
Mild discomfort
Moderate symptoms
Severe reaction
How sensitive are you to strong fragrances or perfumes?
*
1
2
3
4
5
Please rate your overall intolerance to environmental triggers using the scale below.
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Submit Assessment
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