MCS Severity and Functional Impact Pre-Screening Questionnaire $1 donation

MCS Severity and Functional Impact Pre-Screening Questionnaire

Purpose: To help a person describe their chemical sensitivities, symptoms, daily limitations, protective measures, and possible severity level before seeking assessment from a qualified healthcare professional.

Important disclaimer:

This questionnaire does not diagnose Multiple Chemical Sensitivity and does not replace the official QEESI, a medical examination, or professional evaluation. The result is only an estimated severity range that may help the participant communicate with a doctor.

Your uploaded clinical protocol describes MCS as chronic, with recurrent symptoms following low-level exposure to multiple unrelated chemicals. It also emphasizes symptom improvement when triggers are removed, involvement of multiple body systems, and difficulty maintaining daily activities or accessing healthcare.

---

Part 1 — Exposure Reactions

During the last three months, how strongly have you reacted to each item?

Score each answer:

0 — No reaction

1 — Mild

2 — Moderate

3 — Severe

4 — Disabling or dangerous

1. Perfume, cologne, deodorant, or scented body products

2. Laundry detergent, dryer sheets, or fabric softener

3. Cleaning products or disinfectants

4. Air fresheners, scented candles, or essential-oil diffusers

5. Cigarette smoke, vaping, wood smoke, or cannabis smoke

6. Gasoline, diesel exhaust, traffic fumes, or machinery exhaust

7. Paint, varnish, glue, solvents, or construction materials

8. Pesticides, insecticides, herbicides, or agricultural chemicals

9. New furniture, carpeting, mattresses, plastics, or vinyl

10. Hair products, cosmetics, or personal-care products

11. Mold, damp buildings, or musty environments

12. Gas appliances, propane, natural gas, or combustion fumes

13. Hospitals, clinics, pharmacies, or dental offices

14. Hotels, shops, restaurants, public transportation, or other indoor public spaces

15. Outdoor pollution, industrial emissions, gas wells, or fracking-related air pollution

Exposure Reaction Score: ____ / 60

---

Part 2 — Symptoms After Exposure

Score each symptom from 0 to 4 using the same scale.

1. Headache or pressure in the head

2. Facial, sinus, trigeminal, jaw, or dental-type pain

3. Dizziness, imbalance, weakness, or near-fainting

4. Confusion, disorientation, or brain fog

5. Memory or concentration problems

6. Extreme fatigue or exhaustion

7. Breathing difficulty, wheezing, or chest tightness

8. Heart racing, palpitations, or chest discomfort

9. Swelling of the face, neck, throat, or nasal passages

10. Nausea, stomach pain, diarrhea, or other digestive symptoms

11. Muscle, nerve, or joint pain

12. Trembling, agitation, irritability, or neurological overstimulation

13. Tinnitus or sound sensitivity

14. Insomnia or inability to sleep after exposure

15. Symptoms involving several different body systems

Symptom Score: ____ / 60

---

Part 3 — Pattern of Illness

Answer Yes or No.

1. Is the condition chronic or repeatedly recurring?

2. Do the same exposures repeatedly produce similar symptoms?

3. Can very small amounts trigger symptoms?

4. Do several unrelated chemicals trigger reactions?

5. Do symptoms improve when the exposure is removed?

6. Do reactions affect more than one organ or body system?

7. Have your sensitivities increased or spread to additional substances over time?

8. Can a reaction continue for hours, days, weeks, or longer after the exposure ends?

Yes answers: ____ / 8

These questions reflect the consensus characteristics listed in your medical verification: chronicity, reproducible reactions, symptoms at low exposure levels, reactions to unrelated chemicals, improvement with avoidance, and involvement of multiple organ systems.

---

Part 4 — Daily-Life Impact

Score each item from 0 to 4.

0 — No limitation

1 — Some difficulty

2 — Regular limitation

3 — Severe limitation

4 — Unable to do safely

1. Working or attending school

2. Shopping for food or supplies

3. Entering public buildings

4. Visiting friends or family

5. Attending medical appointments

6. Riding in a car, ambulance, bus, train, or airplane

7. Staying in a hotel, apartment, shelter, or hospital

8. Using normal bedding, clothing, or laundry products

9. Living with other people

10. Preparing food or using household appliances

11. Sleeping normally

12. Maintaining personal hygiene

13. Exercising or completing basic physical activity

14. Socializing or participating in community life

15. Maintaining an acceptable overall quality of life

Functional Impact Score: ____ / 60

The uploaded medical report uses functional limitation and disruption of activities of daily living as major evidence of severity.

---

Part 5 — Protective Measures and Environmental Displacement

Check every statement that applies.

I avoid scented people whenever possible.

I ask others not to use fragranced products around me.

I must leave an area when chemicals are present.

I regularly wear a basic mask.

I regularly wear a respirator with chemical filters.

I must wear respiratory protection in most public environments.

I must wear respiratory protection almost continuously.

I have sealed or specially prepared a room.

I need air purification or increased ventilation.

I cannot tolerate ordinary cleaning products.

I cannot tolerate most hospitals or medical offices.

I have changed jobs or stopped working because of exposures.

I have changed homes because of chemical exposures.

I have lived in a vehicle, tent, remote area, or outdoors to avoid exposures.

I currently have no reliably safe indoor environment.

Number checked: ____ / 15

The Canary Islands protocol specifically recognizes mask use, relocation, environmental control, “white areas,” chemical-free rooms, ventilation, unscented products, and avoiding triggers as important indicators and accommodations.

---

Part 6 — Recovery Time

After a significant exposure, how long does it usually take you to return to your previous baseline?

0 — No noticeable reaction

1 — Less than one hour

2 — Several hours

3 — One to three days

4 — Four days to two weeks

5 — Several weeks or longer

6 — I do not fully return to my previous baseline

Recovery score: ____ / 6

---

Preliminary Severity Result

Add:

Exposure Reaction Score

Symptom Score

Functional Impact Score

Core Total: ____ / 180

The total should not be used alone. The protective-measures section, relocation, inability to access healthcare, respirator dependence, and recovery time may indicate greater severity even when a person underreports symptoms.

Estimated Level 1 — Mild Chemical Sensitivity

Typical pattern:

Reactions are noticeable but generally manageable.

The person remains able to work, shop, travel, socialize, and enter most buildings.

Avoidance is occasional.

A respirator is not normally required.

Recovery is usually rapid.

Suggested action: Track exposures and discuss recurring symptoms with a healthcare professional.

Estimated Level 2 — Moderate MCS Pattern

Typical pattern:

Several unrelated products trigger repeatable symptoms.

Public places and fragranced environments are becoming difficult.

Daily activities are limited but remain possible with planning.

A mask or respirator may occasionally be needed.

Recovery may require hours or days.

Suggested action: Complete an official QEESI and seek evaluation from a clinician familiar with MCS or environmental intolerance.

Estimated Level 3 — Severe MCS Pattern

Typical pattern:

Low-level exposures trigger substantial symptoms involving multiple body systems.

Work, shopping, healthcare, travel, and social contact are seriously restricted.

Respiratory protection is used frequently.

The person may have changed work or residence.

Reactions may last days or weeks.

A controlled living environment is increasingly necessary.

Suggested action: Prompt professional assessment, written medical documentation, an exposure-reduction plan, and healthcare accommodations.

Estimated Level 4 — Very Severe or Disabling MCS Pattern

Typical pattern:

Multiple common products seriously affect health.

A respirator is required almost continuously or whenever another person approaches.

Ordinary housing, hospitals, transportation, and public buildings may be intolerable.

The person has moved, become isolated, or lives remotely or outdoors because of exposures.

Basic activities of daily living and access to medical care are profoundly restricted.

Reactions may continue for weeks or months.

There may be no consistently safe indoor environment.

Your uploaded physician’s report classified Grade IV based particularly on reactions to multiple products, almost-continuous mask use, serious health effects, and having to change residence.

Suggested action: Urgent referral to an MCS-informed physician, written accommodation plan, safe healthcare protocol, and assessment of housing, disability, and support needs.

---

Automatic Professional-Referral Flags

Regardless of the score, recommend medical evaluation when the person reports:

Breathing difficulty or chest tightness

Fainting, seizures, severe confusion, or loss of coordination

Throat or facial swelling

Serious medication reactions

Inability to obtain food, water, shelter, or medical care safely

Almost-continuous respirator use

Having to abandon housing because of exposures

Being unable to enter any available medical facility

Symptoms lasting weeks or progressively worsening

For chest pain, severe breathing difficulty, loss of consciousness, or signs of anaphylaxis, the questionnaire should say to seek emergency care rather than relying on the screening result.

---

Result Statement for the Website

> Your answers suggest an estimated MCS severity range of Level __.

This is not a diagnosis. This result reflects the reported frequency of reactions, symptom severity, functional impact, protective measures, recovery time, and environmental limitations. Please save or print your result and take it to a qualified healthcare professional. A clinician may use a validated instrument such as the official QEESI, medical history, examination, and other appropriate assessments.