As part of my process of researching chemical/food intolerances I have developed this survey to gather some basic information about chemical/food intolerant persons and their intolerances.

Please fill out only one form per household. If members of your family, living outside your household, have an intolerance please encourage them to fill out a survey form, or with their permission fill out a separate form on their behalf. If you would like to be included in any follow up questions, please fill in your email address at the end of the survey. Names and email address, if given, are not recorded with your answers.

For the purpose of this survey:

• intolerance or chemical intolerance is understood to refer to any chemical or food or environmental intolerance or sensitivity;

• household is understood to mean those persons living with you that you consider a part of your family;

• an explanation of what an intolerance is can be found by clicking here.