PINK DISEASE is babyhood mercury poisoning caused when babies with a
heightened sensitivity to mercury were exposed to products containing
mercury such as teething powders, calomine lotion, mercurocrome,
diarrhoea medicine and worming preparations. The symptoms included
weepy red rash, peeling skin, lethargy, anaemia, sensitivity to light,
respiratory distress,and general ill health. About 25% of babies with
Pink Disease died. Once mercury was removed from teething powders,
Pink Disease became a rare disease. Only one in 500 babies given
teething powders were diagnosed as having Pink Disease.
Some Pink Disease victims have suffered from poor health or become ill
later in life following further exposure to mercury, particularly from
the most common type of dental filling, which contains 50% mercury.
NAME:(optional) ................................
EMAIL:(optional) ................................
ADDRESS:(optional) ................................
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YEAR OF BIRTH: 19____
MALE/FEMALE
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PRELIMINARY QUESTIONS
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TO ANSWER: Circle Y=Yes,N=No,U=Unknown, OR fill in requested details.
Q1. Do you have Multiple Sclerosis? ........................ Y N
Q2. Do you have Lupus? .................................... Y N
Q3. Do you have Bronchiecstasis? .......................... Y N
Q4. Do you have Solar Urticaria? .......................... Y N U
Q5. Do you have rheumatoid arthritis?...................... Y N U
Q6. Have you had mercury poisoning? ....................... Y N U
Q7. Do you have a serious psychiatric disorder? If yes,
what type? ____________________________________________ Y N U
Q8. If you answered Y to any of the above,age of onset: ______years
Q9. If you answered Y to any of the above, CAUSE, if known _________
Q10. Have you had any poisoning episode (food/chemical etc.) Y N U
Q11. Are you ultra-sensitive to any heavy metals? .......... Y N U
Q12. Did you have Pink Disease ............................. Y N U
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PART 1.
SYMPTOMS SUFFERED AS A BABY/TODDLER
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Symptoms suffered in babyhood:
TO ANSWER: Circle the appropriate answer: Y = Yes
N = No
U = Unknown
AND fill in any other requested details
A1. Red rash .............................................. Y N U
A2. Skin peeled off in layers ............................. Y N U
A3. Clammy hands and feet ................................. Y N U
A4. Very physically fragile ............................... Y N U
A5. Constant crying until completely exhausted ............ Y N U
A6. Bashed head or body against cot or other objects ...... Y N U
A7. Spent time in hospital (if yes, how long? ______ days) Y N U
A8. Did your doctor decline to put you in hospital because
you were too sick and nothing could be done to help? Y N U
A9. Had to be kept in dark room because of photophobia
(acute sensitivity to light). ........................ Y N U
A10. Putrid Body odour or motions .......................... Y N U
A11. Lost appetite ......................................... Y N U
A12. Lost weight ........................................... Y N U
A13. Lost muscle tone (eg. like a rag doll) ............... Y N U
A14. Sucked or chewed fingers/hands. ...................... Y N U
A15. Any type of anaemia? If yes, what type? _______________ Y N U
A16. Who gave you the above information? ........... _____________
QUESTIONS A16 TO A21 ARE TO BE ANSWERED
BY PEOPLE WHO HAD PINK DISEASE
A17. If you were already walking when you got Pink Disease,did
you have to learn to walk again? ..................... Y N U
A18. If not walking when you got Pink Disease, how old were
you when you first walked? ................ _______months
A19. Age of onset of pink disease. ................ _______months
A20. Cause of the disease (if known). ............. _____________
A21. What treatment, if any, where you given? .... _____________
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PART 2.
CURRENT SYMPTOMS:
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TO ANSWER: Circle the appropriate answer: N = Never
R = Rarely
S = Sometimes
O = Often
A = Always
yes = yes
no = no
AND fill in any other requested details
EYES
Have you had or do you have any of the following?
B1. Spots or flashes of light (falling like rain before eyes). N R S O A
B2. Tunnel vision .......................................... N R S O A
B3. Night blindness ......................................... N R S O A
B4. Sensitivity to sunlight (need sunglasses even in winter) N R S O A
B5. Sockets of eyes ache .................................... N R S O A
B6. Retinitis (inflammation of the retina) ................. N R S O A
B7. Keratitis (inflammation of the cornea) ................. N R S O A
B8. Dimness of vision in one or both eyes? .................. N R S O A
B9. Short/long sighted. If yes, which? _____________________ yes no
B10. If yes, at what age did you first get glasses. __________
B11. Retinitus Pigmentosa ................................... yes no
B12. Corneal dystrophy/degeneration ......................... yes no
B13. Been prescribed or used Vitamin A for improved vision .. yes no
B14. Been prescribed or used any other vitamins of minerals
(eg: Vitamin B2, Zinc) for improved vision. If yes,
what? ___________________________________________________ yes no
MOUTH & THROAT
Have you had or do you have any of the following?
C1. Thyroid treatment or problems............................. N R S O A
C2. Have trouble swallowing ................................. N R S O A
C3. Feel as if something is caught in your throat ........... N R S O A
C4. Unexplained coughing fits ............................... N R S O A
C5. Persistent cough ......................................... N R S O A
C6. Pain when yawning ....................................... N R S O A
C7. Clenching or grinding of teeth in sleep ................. N R S O A
C8. Metallic taste in mouth ................................. N R S O A
C9. Swelling of parotid glands (cheek to ear) ............... N R S O A
C10. Swelling of Submaxillary Glands (under jaw) .............. N R S O A
C11. Treatment for T.M.J. (Temporomandibular joint) ........... N R S O A
C12. Excessive cavities in teeth. .......................... yes no
C13. Early loss of teeth. If yes, at what age? __________Years yes no
C14. Do you have dentures? If yes, at what age? ______Years yes no
C15. Any amalgam fillings in teeth? If yes, how many? ________ yes no
C16. (a) Have you had all your amalgams removed? yes no
(b) If yes, by a dentist specialising in amalgam removal? yes no
(c) Was the removal followed by a mercury detoxification
program? yes no
(d) Has your health improved since the amalgam removal? yes no
If yes, how much? __________________________________
(e) Has your health worsened since the amalgam removal? yes no
If yes, how much? __________________________________
BLOOD
Have you had or do you have any of the following?
D1. Iron deficiency anaemia. ................................ N R S O A
D2. Vitamin B12 (pernicious) anaemia. ....................... N R S O A
D3. Any other type of anaemia? If so, type? _________________ N R S O A
D4. Frequent bouts of anaemia for no known reason? .......... N R S O A
D5. Excess iron in your blood? .............................. N R S O A
D6. Unexplained low haemoglobin (blood) count? ............. N R S O A
D7. Any unexplained unusual results from blood tests? ....... N R S O A
MUSCLES & BONES
Have you had or do you have any of the following?
E1. Poly-myalgia (painful muscles & ligaments, especially in
your feet, elbows and knees) ............................ N R S O A
E2. Arthritis like symptoms ................................ N R S O A
E3. Poor muscle tone in general or loss of muscle tone ...... N R S O A
E4. Pectoral and pelvic girdle (hips "click") ............... N R S O A
E5. Spurs on heels .......................................... N R S O A
E6. Costal chondritis (painful cartilage connecting ribs &
sternum) ................................................ N R S O A
E7. Loss of strength in arms (can't hold things above head). . N R S O A
E8. Osteoporosis (brittleness and softness of bones). ........ yes no
CO-ORDINATION
Have you done or do you do any of the following?
F1. Do you drift when walking (into walls, etc.) ............. N R S O A
F2. Do you stumble when walking. ............................. N R S O A
F3. Do you have poor hand/eye co-ordination (eg. go to open
fridge and miss handle completely, type/write words in
a jumbled fashion). ...................................... N R S O A
F4. Do you have a poor sense of distance? .................. N R S O A
F5. Do you have a poor sense of direction? .................. N R S O A
F6. Are you clumsier than average? If so, lots? ______________ N R S O A
F7. Do you jumble your words and/or have difficulty
communicating what you are thinking in words or writing? . N R S O A
ALLERGIES & CHEMICAL SENSITIVITIES
Are you allergic/sensitive to any of the following?
G1. Foods? If yes, please list? ____________________________ yes no
G2. Medicines? If yes, please list? ________________________ yes no
G3. Cosmetics? If yes,please list? __________________________ yes no
G4. Chemicals? If yes, please list? ________________________ yes no
G5. Metals? If yes, please list? ___________________________ yes no
G6. Food additives? If yes, please list? ___________________ yes no
G7. Do you suffer from hayfever? If so, severely? ____________ N R S O A
GENERAL
Have you had or do you have any of the following?
H1. Headaches? .............................................. N R S O A
H2 . Migraines? If yes, how severe? _________________________ N R S O A
H3. Unexplained tiredness? .................................. N R S O A
H4. Do you feel "hungover" in the mornings for no reason? ... N R S O A
H5. Chronic tiredness? ...................................... N R S O A
H6. Do you prefer salty foods to sweet foods? ............... N R S O A
H7. Do you prefer sweet foods to salty foods? ............... N R S O A
H8. Do you feel the cold more than average? ................. N R S O A
H9. Do you feel the heat more than average? ................. N R S O A
H10. Do you sweat excessively? ................................ N R S O A
H11. Do you sweat excessively on your face? .................. N R S O A
H12. Do you have numbness in any part of the body? ........... N R S O A
H13. Ear Problems? What type? _________________________________ N R S O A
H14. Excessive pain if you bump your legs/arms? ............. N R S O A
H15. Excessive body odour? ................................... N R S O A
H16. Poor nutritional absorption? ............................. N R S O A
H17. Do you have digestive problems?........................... N R S O A
H18. Do you have constipation? ................................ N R S O A
H19. Do you have diarrhea? .................................... N R S O A
H20. Trouble losing weight? ................................... N R S O A
H21. Trouble gaining weight? .................................. N R S O A
H22. Do you have a poor immune system? ....................... N R S O A
H23. Have you suffered from any form on cancer? If yes,
what type? _____________________________________________ yes no
H24. What type of medication, if any, are you on? _____________
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H25. Kidney problems?If yes, type? ____________________________ yes no
H26. Liver problems? If yes, type? ____________________________ yes no
H27. Bladder problems? If yes, type? _________________________ yes no
H28. Have you been DIAGNOSED as having Chronic Fatigue Syndrome
or Myalgic Encepthalomyelitis? If yes, CFS or ME? _______ yes no
H29. Have you been DIAGNOSED as having Multiple Sclerosis? ... yes no
H30. Have you been DIAGNOSED as having any auto-immune disorder? yes no
H31. Have you been DIAGNOSED as having Lupus? ................. yes no
H32. Does your doctor suspect you have an auto-immune disorder? yes no
H33. Do you suffer from loss of hearing? ..................... yes no
H34. Do you have mis-shapen fingers or nails? ................ yes no
H35. Do you have problems with your hands and/or feet? If yes,
give details. ___________________________________________ yes no
H36. Do you have Rheumatoid Arthritis? ....................... yes no
H37. Do you have Raynaud's Syndrome? .......................... yes no
H38. Do you have Scleroderma?................ ................. yes no
H39. Do you suffer from Restless Legs Syndrome?................ yes no
H40. Have you had exposure to mercury from any source other
than dental amalgams? Mercury is still found in a number
of medicines, contact lens solutions, and in the work
place. If yes, give details at the end of the survey .... yes no
H41. Do you have Ross River Fever? ............................ yes no
SKIN
Have you had or do you have any of the following?
J1. Skin problems? If yes, what sort? _______________________ N R S O A
J2. Icthyotic skin (dry scaly skin)? ........................ N R S O A
J3. Psoriasis (red patches covered by grey scaly skin)? ..... N R S O A
J4. Is you skin prone to rashes? ............................ N R S O A
J5. Do you sunburn easily? .................................. N R S O A
J6. Do you get a rash from sunlight exposure?................. N R S O A
J7. Do you get red spots from sunlight exposure? ............ N R S O A
J8. Are you prone to dermatitis? ............................ N R S O A
J9. Is your skin dry (for a person your age)? ............... N R S O A
J10. Was your skin dry as a child? ........................... N R S O A
J11. Did you have wrinkly hands as a child? ................... N R S O A
J12. Are you unusually fair skinned (not inherited)? .......... N R S O A
HEART & LUNGS
Have you had or do you have any of the following?
K1. Asthma? If you do, age of onset: ____________________years N R S O A
K2. Breathlessness from even minor exertion? ................ N R S O A
K3. Bronchitis? ............................................. N R S O A
K4. Chest/heart pains (angina attacks)? ..................... N R S O A
K5. Tachycardia (racing heart)? ............................. N R S O A
K6. Poor blood circulation (pins & needles)? ................ N R S O A
K7. Bronchiectasis (dilation of the small bronchial tubes)? .. yes no
K8. Any other lung disorder? If yes, type? ___________________ yes no
K9. Mitral valve problems? ................................ yes no
K10. Heart murmur? ........................................... yes no
K11. Heart problems? ......................................... yes no
K12. Do you suffer from unexplained dizzy spells? ............. yes no
K13. Do you have High/Low/Normal blood pressure? ............. High Low Normal
STRESS LEVEL, EMOTIONAL
WELL-BEING & PERSONALITY
Have you had or do you have any of the following?
L1. Nightmares? If yes, how bad? ____________________________ N R S O A
L2. Insomnia? ................................................ N R S O A
L3. Do you need excess sleep? If yes, how much sleep to you
need each day? ___________________________________________ N R S O A
L4. Depression? If yes, how severe? ________________________ N R S O A
L5. Suicidal thoughts? ....................................... N R S O A
L6. Feelings of helplessness? ............................... N R S O A
L7. Do you suffer from forgetfulness? ....................... N R S O A
L8. Do you lack self-confidence? ............................ N R S O A
L9. Are you a nervous person? ............................... N R S O A
L10. Do you lack attention in conversation? .................. N R S O A
L11. Are you shy? ............................................ N R S O A
L12. Are you sensitive to noise? ............................ N R S O A
L13. Are you a "loner" or do others think you are a loner? ... N R S O A
L14. Are you moody or do others think you moody? ............. N R S O A
L15. What is your stress tolerance? .......................... Low Average High
L16. How much stress do you suffer? .......................... Low Average High
L17. What is your emotional level? ............................ Low Average High
L18. Physical health level on a scale of 1 to 10 (10 best)..... ______
L19. Have you been diagnosed as having clinical depression? ... yes no
L20. Have you been diagnosed as having bipolar disorder (manic
depression)? ............................................. yes no
L21. Have you been diagnosed as having schizophrenia? ......... yes no
L22. Have you been diagnosed as having a schizoid personality? yes no
L23. Have you been diagnosed as having any mental illness? .... yes no
L24. If you have answered YES to any one of questions L18, L19,
L20, L21 OR L22, is the illness inherited? .............. yes no unknown
BACKGROUND INFORMATION
Have you had -
M1. Whooping Cough .......................................... yes no
M2. German Measles .......................................... yes no
M3. Measles ....... .......................................... yes no
M4. Glandular Fever .......................................... yes no
M5. Scarlet Fever ........................................... yes no
FOR WOMEN ONLY:
N1. Have you suffered from fertility problems? .............. yes no
N2. Have you had any miscarriages? .......................... yes no
N3. Have you had any still-births? .......................... yes no
N4. Have you had a hysterectomy? If yes, why & what age? ... yes no
Why?_____________________________________Age?_____________
N5. Do you or did you have excessively painful & debilitating
period pain? ...........................................
N6. Did you suffer any other gynaecological problems? ...... N R S O A
N7. Is your hair unusually thin? ............................ N R S O A
N8. Do you suffer from unexplained hair loss? ............... N R S O A
N9. Do you need to wear a wig? ............................. yes no
N10. Have you given birth to a handicapped child? If yes,
what type of handicap? ___________________________________ yes no
N11. Do you or did you have premenstrual syndrome? If yes, how
bad? (slight/average/severe/incapacitating) _____________ N R S O A
MEN ONLY:
P1. Have you had fertility problems? ........................ yes no
P2. Have you suffered from Young's Syndrome? ................. yes no
P3. Have you had any other men's problems? .................. yes no
P4. Do you have unexplained hair loss (not inherited)? ....... yes no
YOUR COMMENTS:
You may have problems not mentioned above, or be suffering very
severely, or some of the problems you have have an explanation (eg:
your kidney problems are inherited, or your health problems are caused
by old age, or your hearing loss is due to industrial deafness).
PLEASE GIVE US ANY INFORMATION YOU THINK MAY BE USEFUL.
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RETURN THIS SURVEY TO:
Diane Farnsworth,
29/26-38 Halliday Street,
EAGLEBY, QLD., AUSTRALIA, 4207.
Internet: www.users.bigpond.com/difarnsworth/
Email: difarnsworth@bigpond.com
