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Toxicant Induced Loss of Tolerance (TILT)

Please complete the TILT screening survey below.

Thank you!

Country

Please provide your ZIP or Postal code:

QEESI©
Quick Environmental Exposure and Sensitivity Inventory V-1
The purpose of this questionnaire is to help identify health problems you may be having and to understand your responses to various exposures. Complete the survey, describing how you are now.

Prior to activating the "SUBMIT" button at the end of the survey Please consider saving your responses and/or making a printout of your responses using your browser options.

Doctors:
This instrument is provided free of charge. Please do not charge patients for its use. Physicians are encouraged to use the QEESI©, as part of their clinical practice with patients when chemical 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 share the
interpretation sheet with 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, MC 7794
San Antonio, TX 78229-3900
Phone: 210-358-5870
Twitter: @HoffmanTILT
Email: HoffmanTILT@uthscsa.edu

Additional information on scoring and interpreting the QEESI© can be viewed at www.chemicalexposures.com
The pdf version of the QEESI© is available at http://familymed.uthscsa.edu/qeesi.pdf

Dr. Miller is not available to consult on individual cases or to serve as an expert witness.

Chemical Exposures
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 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 exposure. For exposures that do not bother you, answer "0." Do not leave any items blank.

For each item, click on one number only:
[0 = not at all a problem] [5 = moderate symptoms] [10 = disabling symptoms]

1. Diesel or gas engine exhaust

* must provide value

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2. Tobacco smoke

* must provide value

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3. Insecticide

* must provide value

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4. Gasoline (For example, at a service station while filling the gas tank)

* must provide value

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5. Paint or paint thinner

* must provide value

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6. Cleaning products such as disinfectants, bleach, bathroom cleansers or floor cleaners

* must provide value

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7. Certain perfumes, air fresheners or other fragrances

* must provide value

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8. Fresh tar or asphalt

* must provide value

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9. Nail polish, nail polish remover, or hairspray

* must provide value

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10. New furnishings such as new carpeting, a new soft plastic shower curtain or the interior of a new car

* must provide value

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Total Chemical Intolerance Score (0-100):

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Name any additional chemical exposures that make you feel ill and score them from 0 to 10:

1. Chlorinated tap water

* must provide value

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2. Particular foods, such as candy, pizza, milk, fatty foods, meats, barbecue, onions, garlic, spicy foods, or food additives such as MSG

* must provide value

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3. Unusual cravings, or eating any foods as though you were addicted to them; or feeling ill if you miss a meal

* must provide value

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4. Feeling ill after meals

* must provide value

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5. Caffeine, such as coffee, tea, Snapple, cola drinks, Big Red, Dr. Pepper or Mountain Dew, or chocolate

* must provide value

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6. Feeling ill if you drink or eat less than your usual amount of coffee, tea, caffeinated soda or chocolate, or miss it altogether

* must provide value

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7. Alcoholic beverages in small amounts such as one beer or a glass of wine

* must provide value

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8. Fabrics, metal jewelry, creams, cosmetics, or other items that touch your skin

* must provide value

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9. Being unable to tolerate or having adverse or allergic reactions to any drugs or medications (such as antibiotics, anesthetics, pain relievers, x-ray, contrast dye, birth control pills), or to an implant, prosthesis, contraceptive chemical or device, or other medical, surgical or dental material or procedure

* must provide value

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10. Problems with any classical allergic reactions (asthma, nasal symptoms, hives, anaphylaxis or eczema) when exposed to allergens such as: tree, grass or weed pollen, dust, mold, animal dander, insect stings or particular foods

* must provide value

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Total Other Intolerance Score (0-100):

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1 Problems with your muscles or joints, such as pain, aching, cramping, stiffness or weakness? (MS)

* must provide value

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2. Problems with burning or irritation of your eyes, or problems with your airway or breathing, such as feeling short of breath, coughing, or having a lot of mucus, post- nasal drainage, or respiratory infections? (AIR/MM)

* must provide value

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3. Problems with your heart or chest, such as a fast or irregular heart rate, skipped beats, your heart pounding, or chest discomfort? (COR)

* must provide value

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4. Problems with your stomach or digestive tract, such as abdominal pain or cramping, abdominal swelling or bloating, nausea, diarrhea, or constipation? (GI)

* must provide value

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5. Problems with your ability to think, such as difficulty concentrating or remembering things, feeling spacey, or having trouble making decisions? (COG)

* must provide value

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6. Problems with your mood, such as feeling tense or nervous, irritable, depressed, having spells of crying or rage, or loss of motivation to do things that used to interest you? (AFF)

* must provide value

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7. Problems with balance or coordination, with numbness or tingling in your extremities, or with focusing your eyes? (NM)

* must provide value

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8. Problems with your head, such as headaches or a feeling of pressure or fullness in your face or head? (HEAD)

* must provide value

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9. Problems with your skin, such as a rash, hives or dry skin? (SKIN)

* must provide value

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10. Problems with your urinary tract or genitals, such as pelvic pain or frequent or urgent urination? (For women: or discomfort or other problems with your menstrual period?) (GU)

* must provide value

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Total Symptom Score (0-100):

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NO=0

YES=1

1. Do you smoke or dip tobacco once a week or more often?

* must provide value

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2. Do you drink any alcoholic beverages, beer, or wine once a week or more often?

* must provide value

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3. Do you consume any caffeinated beverages once a week or more often?

* must provide value

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4. Do you routinely (once a week or more) use perfume, hairspray, or other scented personal care products?

* must provide value

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5. Has either your home or your workplace been sprayed for insects or fumigated in the past year?

* must provide value

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6. In your current job or hobby, are you routinely (once a week or more) exposed to any chemicals, smoke or fumes?

* must provide value

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7. Other than yourself, does anyone routinely smoke inside your home?

* must provide value

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8. Is either a gas or propane stove used for cooking in your home?

* must provide value

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9. Is a scented fabric softener (liquid or dryer sheet) routinely used in laundering your clothes or bedding?

* must provide value

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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, or mood disorders; medications for sleep; or recreational or street drugs?

* must provide value

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Masking Index (0-10):
(Total number of YES answers)

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1. Your diet?

* must provide value

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2. Your ability to work or go to school?

* must provide value

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3. How you furnish your home?

* must provide value

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4. Your choice of clothing?

* must provide value

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5. Your ability to travel to other cities or drive a car?

* must provide value

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6. Your choice of personal care products, such as deodorants or makeup?

* must provide value

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7. Your ability to be around others and enjoy social activities, for example, going to meetings, church, restaurants, etc.?

* must provide value

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8. Your choice of hobbies or recreation?

* must provide value

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9. Your relationship with your spouse or family?

* must provide value

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10. Your ability to clean your home, iron, mow the lawn, or perform other routine chores?

* must provide value

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Total Life Impact Score (0-100):

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Interpreting the QEESI©

Information on the development of this instrument, its interpretation, and results for several populations have been published (Miller and Prihoda 1999a,b). Proposed ranges for the QEESI©'s scales and guidelines for their interpretation appear in Tables 1 and 2 below:

Table 1. Criteria for low, medium, and high scale scores

Total Symptom Score (0-100):

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Total Chemical Intolerance Score (0-100):

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Total Other Intolerance Score (0-100):

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Total Life Impact Score (0-100):

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Masking Index (0-10):

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Scoring the 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.

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. The QEESI© displays 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

Additional information on scoring and interpreting the QEESI© can be viewed at www.chemicalexposures.com

Prior to activating the "SUBMIT" button at he end of the survey Please consider saving your responses and/or making a printout of your responses using your browser options.

HEAD = Head-related symptoms

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COG = Cognitive symptoms

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AFF = Affective symptoms

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NM = Neuromuscular symptoms

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MS = Musculoskeletal symptoms

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SKIN = Skin-related symptoms

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GU = Genitourinary symptoms

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GI = Gastrointestinal symptoms

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COR = Heart/chest-related symptoms

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AIR/MM= Airway or mucous membrane symptoms

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You can print a copy and fill in the "target" diagram below.
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 building, then go back through the survey and indicate how you were before the exposure event. Use different colors or symbols (circles, squares) for "before" and "after."

STAR Instructions:. 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.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.