"Quick Environmental Exposure Sensitivity Inventory (Qeesi) - University of Texas Health Science Center at San Antonio" - Texas

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This validated questionnaire, The Quick Environmental Exposure and Sensitivity Inventory, or
©
QEESI
, helps researchers, doctors, and their patients identify individuals with multiple chemical
©
intolerances. The QEESI
involves personal health information. Its use should be restricted to
©
patients, their personal physicians, and researchers using the QEESI
as part of a protocol approved
by an appropriate institutional review board (such as one registered with the U.S. Department of
Health and Human Services Office for Human Research Protections).
©
Please do not re-post the QEESI
or its image on any websites without written permission.
Doctors
This instrument is provided free of charge. Please do not charge patients for its use. Physicians are
©
, as part of their clinical practice with patients when chemical
encouraged to use the QEESI
intolerance or TILT (Toxicant Induced Loss of Tolerance) is suspected.
Patients
©
Patients are welcome to download and complete the QEESI
, and are encouraged to take it and the
interpretation sheet to their doctors.
Researchers
©
Researchers must contact Dr. Claudia Miller for permission to use the QEESI
in their studies.
Contact
Dr. Claudia Miller, Professor
Department of Family & Community Medicine
University of Texas School of Medicine at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229-3900
Fax: (210) 567-7457
Email:
MillerCS@uthscsa.edu
Additional information is available at www.drclaudiamiller.com.
Dr. Miller is not available to consult on individual cases or to serve as an expert witness.
This validated questionnaire, The Quick Environmental Exposure and Sensitivity Inventory, or
©
QEESI
, helps researchers, doctors, and their patients identify individuals with multiple chemical
©
intolerances. The QEESI
involves personal health information. Its use should be restricted to
©
patients, their personal physicians, and researchers using the QEESI
as part of a protocol approved
by an appropriate institutional review board (such as one registered with the U.S. Department of
Health and Human Services Office for Human Research Protections).
©
Please do not re-post the QEESI
or its image on any websites without written permission.
Doctors
This instrument is provided free of charge. Please do not charge patients for its use. Physicians are
©
, as part of their clinical practice with patients when chemical
encouraged to use the QEESI
intolerance or TILT (Toxicant Induced Loss of Tolerance) is suspected.
Patients
©
Patients are welcome to download and complete the QEESI
, and are encouraged to take it and the
interpretation sheet to their doctors.
Researchers
©
Researchers must contact Dr. Claudia Miller for permission to use the QEESI
in their studies.
Contact
Dr. Claudia Miller, Professor
Department of Family & Community Medicine
University of Texas School of Medicine at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229-3900
Fax: (210) 567-7457
Email:
MillerCS@uthscsa.edu
Additional information is available at www.drclaudiamiller.com.
Dr. Miller is not available to consult on individual cases or to serve as an expert witness.
QEESI
©
©
The Quick Environmental Exposure and Sensitivity Inventory (QEESI
) was developed as a screening questionnaire for
multiple chemical intolerances (MCI). The instrument has four scales: Symptom Severity, Chemical Intolerances, Other Intolerances,
and Life Impact. Each scale contains 10 items, scored from 0 = “not a problem” to 10 = “severe or disabling problem.” A 10-item
Masking Index gauges ongoing exposures that may affect individuals’ awareness of their intolerances as well as the intensity of their
©
responses to environmental exposures. Potential uses for the QEESI
include:
1.
Research—to characterize and compare study populations, and to select subjects and controls.
©
2.
Clinical evaluations—to obtain a profile of patients’ self-reported symptoms and intolerances. The QEESI
can be
administered at intervals to follow symptoms over time or to document responses to treatment or exposure avoidance.
3.
Workplace or community investigations—to identify and assist those who may be more chemically susceptible or who
report new intolerances. Affected individuals should have the option of discussing results with investigators or their
personal physicians.
©
Individuals whose symptoms began or intensified following a particular exposure event can fill out the QEESI
using two different ink
colors, one showing how they were before the event, and the second how they have been since the event. On the cover of the
©
QEESI
is a “Symptom Star” (Figure 1) which provides a graphical representation of patients’ responses on the Symptom Severity
Scale.
Figure 1. QEESI Symptom Star illustrating symptom severity in an individual before and after an exposure event
(e.g., pesticide application, indoor air contaminants, chemical spill)
Symptom Star
HEAD = Head-related symptoms
COG = Cognitive symptoms
AFF = Affective symptoms
NM = Neuromuscular symptoms
MS = Musculoskeletal symptoms
SKIN = Skin-related symptoms
GU = Genitourinary symptoms
GI = Gastrointestinal symptoms
COR = Heart/chest-related symptoms
AIR/MM = Airway or mucous membrane symptoms
Before exposure event
After exposure event
©
For additional copies of the QEESI
, contact Claudia S. Miller, M.D., M.S., University of Texas Health Science Center at San Antonio,
Department of Family and Community Medicine, 7703 Floyd Curl Drive (222 MCS), San Antonio, Texas 78229-3900. Phone: (210)
567-7407; fax: (210) 567-7457; email: millercs@uthscsa.edu. For further information see Chemical Exposures: Low Levels and High
Stakes by Nicholas A. Ashford and Claudia S. Miller, John Wiley & Sons, 1998 (1-800-225-5945) http://www.wiley.com.
Date:
ID:
— Chemical Exposures —
QEESI
©
The following items ask about your responses to various odors or chemical exposures.
Please indicate whether or not these odors or exposures would make you feel sick, for
example, you would get a headache, have difficulty thinking, feel weak, have trouble
breathing, get an upset stomach, feel dizzy, or something like that. For any exposure
that makes you feel sick, on a 0-10 scale rate the severity of your symptoms with that
Quick Environmental Exposure
exposure. For exposures that do not bother you, answer “0.” Do not leave any items
blank.
and Sensitivity Inventory V-1
For each item, circle one number only:
[0 = not at all a problem]
[5 = moderate symptoms]
T
he purpose of this questionnaire is to help identify health problems you may be
[10 = disabling symptoms]
having and to understand your responses to various exposures. Complete pages 1-5,
describing how you are now. Then fill in the “target” diagram below.
1.
Diesel or gas engine exhaust
0 1 2 3 4 5 6 7 8 9 10
If your health problems began suddenly or became much worse after a particular
exposure event, such as a pesticide exposure or moving to a new home or office
2.
Tobacco smoke
0 1 2 3 4 5 6 7 8 9 10
building, then go back through pages 1-3 and indicate how you were before the
3.
Insecticide
0 1 2 3 4 5 6 7 8 9 10
exposure event. Use different colors or symbols (circles, squares) for “before” and
“after.”
4.
Gasoline, for example at a service station while filling the gas
0 1 2 3 4 5 6 7 8 9 10
tank
Symptom Star
5.
Paint or paint thinner
0 1 2 3 4 5 6 7 8 9 10
6.
Cleaning products such as disinfectants, bleach, bathroom
0 1 2 3 4 5 6 7 8 9 10
cleansers or floor cleaners
7.
Certain perfumes, air fresheners or other fragrances
0 1 2 3 4 5 6 7 8 9 10
8.
Fresh tar or asphalt
0 1 2 3 4 5 6 7 8 9 10
9.
Nailpolish, nailpolish remover, or hairspray
0 1 2 3 4 5 6 7 8 9 10
10.
New furnishings such as new carpeting, a new soft plastic
0 1 2 3 4 5 6 7 8 9 10
shower curtain or the interior of a new car
Total Chemical Intolerance Score (0-100):
Name any additional chemical exposures that make you feel ill and score them from 0
to 10:
Instructions: Place page 3 so that it lies next to this page. Place a
dot on the corresponding spoke for each symptom item. Connect
these points. Indicate “before” and “after” scores by using different
colors or dotted versus solid lines.
1
+
— Symptoms —
— Other Exposures —
The following questions ask about symptoms you may have experienced commonly.
The following items ask about your responses to a variety of other exposures. As
Rate the severity of your symptoms on a 0-10 scale. Do not leave any items blank.
before, please indicate whether these exposures would make you feel sick. Rate the
severity of your symptoms on a 0-10 scale. Do not leave any items blank.
For each item, circle one number only:
[0 = not at all a problem]
[5 = moderate symptoms]
For each item, circle one number only:
[10 = disabling symptoms]
[0 = not at all a problem]
[5 = moderate symptoms]
[10 = disabling symptoms]
1.
Problems with your muscles or joints, such as pain, aching,
MS
cramping, stiffness or weakness?
0 1 2 3 4 5 6 7 8 9 10
1.
Chlorinated tap water
0 1 2 3 4 5 6 7 8 9 10
2.
Problems with burning or irritation of your eyes, or
2.
Particular foods, such as candy, pizza, milk, fatty foods,
problems with your airway or breathing, such as feeling
AIR/MM
meats, barbecue, onions, garlic, spicy foods, or food
0 1 2 3 4 5 6 7 8 9 10
short of breath, coughing, or having a lot of mucus, post-
0 1 2 3 4 5 6 7 8 9 10
additives such as MSG
nasal drainage, or respiratory infections?
3.
Unusual cravings, or eating any foods as though you were
0 1 2 3 4 5 6 7 8 9 10
3.
Problems with your heart or chest, such as a fast or
addicted to them; or feeling ill if you miss a meal
COR
irregular heart rate, skipped beats, your heart pounding, or
0 1 2 3 4 5 6 7 8 9 10
4.
Feeling ill after meals
0 1 2 3 4 5 6 7 8 9 10
chest discomfort?
5.
Caffeine, such as coffee, tea, Snapple, cola drinks, Big Red,
4.
Problems with your stomach or digestive tract, such as
0 1 2 3 4 5 6 7 8 9 10
GI
Dr. Pepper or Mountain Dew, or chocolate
abdominal pain or cramping, abdominal swelling or bloating,
0 1 2 3 4 5 6 7 8 9 10
nausea, diarrhea, or constipation?
Feeling ill if you drink or eat less than your usual amount of
6.
coffee, tea, caffeinated soda or chocolate, or miss it
0 1 2 3 4 5 6 7 8 9 10
5.
Problems with your ability to think, such as difficulty
COG
altogether
concentrating or remembering things, feeling spacey, or
0 1 2 3 4 5 6 7 8 9 10
having trouble making decisions?
7.
Alcoholic beverages in small amounts such as one beer or a
0 1 2 3 4 5 6 7 8 9 10
glass of wine
6.
Problems with your mood, such as feeling tense or nervous,
AFF
irritable, depressed, having spells of crying or rage, or loss of
0 1 2 3 4 5 6 7 8 9 10
8.
Fabrics, metal jewelry, creams, cosmetics, or other items
motivation to do things that used to interest you?
0 1 2 3 4 5 6 7 8 9 10
that touch your skin
7.
Problems with balance or coordination, with numbness or
NM
9.
Being unable to tolerate or having adverse or allergic
tingling in your extremities, or with focusing your eyes?
0 1 2 3 4 5 6 7 8 9 10
reactions to any drugs or medications (such as antibiotics,
anesthetics, pain relievers, x-ray contrast dye, vaccines or
8.
Problems with your head, such as headaches or a feeling of
HEAD
0 1 2 3 4 5 6 7 8 9 10
birth control pills), or to an implant, prosthesis,
pressure or fullness in your face or head?
0 1 2 3 4 5 6 7 8 9 10
contraceptive chemical or device, or other medical, surgical
or dental material or procedure
SKIN
9.
Problems with your skin, such as a rash, hives or dry skin?
0 1 2 3 4 5 6 7 8 9 10
10.
Problems with any classical allergic reactions (asthma, nasal
symptoms, hives, anaphylaxis or eczema) when exposed to
10.
Problems with your urinary tract or genitals, such as pelvic
0 1 2 3 4 5 6 7 8 9 10
GU
allergens such as: tree, grass or weed pollen, dust, mold,
pain or frequent or urgent urination? (For women: or
0 1 2 3 4 5 6 7 8 9 10
animal dander, insect stings or particular foods
discomfort or other problems with your menstrual period?)
Total Other Intolerance Score (0-100):
Total Symptom Score (0-100):
2
3
— Impact of Sensitivities —
— Masking Index —
If you are sensitive to certain chemicals or foods, on a scale of 0-10 rate the degree to
The following items refer to ongoing exposures you may be having. Circle “0” if the
which your sensitivities have affected various aspects of your life. If you are not sensitive
answer is “NO,” or if you don’t know whether you have the exposure. Circle “1” if the
or if your sensitivities do not affect these aspects of your life, answer “0.” Do not leave
answer is “YES,” you do have the exposure. Do not leave any items blank.
any items blank.
Circle “0” or “1” only:
How much have your sensitivities affected:
[0 = not at all]
[5 = moderately]
[10 = severely]
1.
Do you smoke or dip tobacco once a week or more often?
NO=0
YES=1
2.
Do you drink any alcoholic beverages, beer, or wine once a
1.
Your diet?
0 1 2 3 4 5 6 7 8 9 10
NO=0
YES=1
week or more often?
2.
Your ability to work or go to school?
0 1 2 3 4 5 6 7 8 9 10
3.
Do you consume any caffeinated beverages once a week or
NO=0
YES=1
more often?
3.
How you furnish your home?
0 1 2 3 4 5 6 7 8 9 10
4.
Do you routinely (once a week or more) use perfume,
4.
Your choice of clothing?
0 1 2 3 4 5 6 7 8 9 10
NO=0
YES=1
hairspray, or other scented personal care products?
5.
Your ability to travel to other cities or drive a car?
0 1 2 3 4 5 6 7 8 9 10
5.
Has either your home or your workplace been sprayed for
NO=0
YES=1
insects or fumigated in the past year?
6.
Your choice of personal care products, such as deodorants
0 1 2 3 4 5 6 7 8 9 10
or makeup?
6.
In your current job or hobby, are you routinely (once a
NO=0
YES=1
week or more) exposed to any chemicals, smoke or fumes?
7.
Your ability to be around others and enjoy social activities,
0 1 2 3 4 5 6 7 8 9 10
for example, going to meetings, church, restaurants, etc.?
7.
Other than yourself, does anyone routinely smoke inside
NO=0
YES=1
your home?
8.
Your choice of hobbies or recreation?
0 1 2 3 4 5 6 7 8 9 10
8.
Is either a gas or propane stove used for cooking in your
9.
Your relationship with your spouse or family?
0 1 2 3 4 5 6 7 8 9 10
NO=0
YES=1
home?
10.
Your ability to clean your home, iron, mow the lawn, or
0 1 2 3 4 5 6 7 8 9 10
9.
Is a scented fabric softener (liquid or dryer sheet) routinely
perform other routine chores?
NO=0
YES=1
used in laundering your clothes or bedding?
Total Life Impact Score (0-100):
10.
Do you routinely (once a week or more) take any of the
following: steroid pills, such as prednisone; pain medications
requiring a prescription; medications for depression, anxiety,
NO=0
YES=1
For copies of the QEESI, call 210-567-7407 or email millercs@uthscsa.edu.
or mood disorders; medications for sleep; or recreational
REFERENCES:
or street drugs?
Background information:
Chemical Exposures: Low Levels and High Stakes (2nd Ed.) by Nicholas A. Ashford and
Claudia S. Miller, John Wiley & Sons, Inc., New York, 1998.
Masking Index (0-10):
Sensitivity, specificity, reliability and validity of the QEESI:
(Total number of YES answers)
Miller CS, Prihoda TJ: The Environmental Exposure and Sensitivity Inventory (EESI): a
standardized approach for measuring chemical intolerances for research and clinical
applications. Toxicology and Industrial Health 15:370-385, 1999.
Miller CS, Prihoda TJ: A controlled comparison of symptoms and chemical intolerances
reported by Gulf War veterans, implant recipients and persons with multiple chemical
sensitivity. Toxicology and Industrial Health 15:386-397, 1999.
Copyright © 1998 Claudia S. Miller. All rights reserved. This work may not be translated or copied
in whole or in part, transmitted in any form or by any means (electronic or mechanical), including
photocopying, recording, storage in an information retrieval system or otherwise, without the
written permission of the author.
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