Online questionnaire

MELISA Questionnaire

MELISA measures Type-IV hypersensitivity to metals, a condition which has been found present in patients suffering from various diseases such as chronic fatigue syndrome, rheumatoid arthritis and various autoimmune conditions. An immunological reaction to metals can be mild or acute and can manifest itself in many ways.

Completing this questionnaire will allow us to check for the typical signs of hypersensitivity and to provide you with a complete, personalised list of metals which could be tested.

1. Personal details

Name(*)

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Date of birth

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Street address

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City

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State / Province

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Postal / Zip code

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Email(*)

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Current profession

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Past profession(s)

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Name of your referring doctor, dentist or health care professional

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What gender were you assigned at birth?

Female
Male
Other
Decline to answer

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Diagnosed disease

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2. Your dental record

Dental restorations are a common cause of metal hypersensitivity

How many amalgam fillings do you have?

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Have you experienced any symptoms such as metallic taste, fatigue, oral burning, ulcers, abnormal fatigue and rashes connected with dental work?

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Have you had your silver amalgam fillings removed or replaced?

Yes
No

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How long did the symptoms last and describe the symptoms?

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Do your gums bleed when you brush your teeth?

Yes
No

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Do you grind your teeth and/or wake up with headache in the morning?

Yes
No

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Do you have dental surgery planned?

Yes
No

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What kind of surgery? titanium implant, bridges, crowns, zirconia implant etc

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3. Metal exposure

Healthcare advances have introduced metals into a whole range of new devices and products, from implantable devices and orthopedic devices to toothpastes and foods. This section covers some of the most common sources of exposure

Do you have (or have you ever had) any metal implants in your body (screws, pins and plates, joint replacement, stents, pacemakers etc?

Yes
No

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Have you had health issues since this device was placed?

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Please type another option here

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Please give any more information that you feel is relevant. Including testing, other symptoms

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What is the name of the device or what was it used for? Do you know which metals it contains (cobalt chromium, titanium stainless steel etc), please list

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If possible, please give product and brand name

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Do you have surgery planned which would involve implanting a metal based device?

Yes
No

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Please give as many details of the device as possible: name, manufacturer and any metal content that you are aware of

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3.1 Occupational Exposure

Workplace exposure is a common trigger for metal hypersensitivity. Certain occupations pose a special risk for metal exposure such as: construction workers, electricians, aircraft workers, hairdressers, wood and paper industry workers, painters, metal workers, textile industry workers, dentists and dental technicians.

Have you been exposed to metals through your work?

Yes
No

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What is/was your occupation and if possible what were the metals that you were exposed to?

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Is anyone in your family exposed to unusually high amounts of metals through their occupation?

Yes
No

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Which metals and what is/was their occupation?

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3.2 Tattoos

Different colour tattoos may contain different metals. Red may be mercury-based and white is titanium-dioxide based for instance .

Do you have any tattoos?

Yes
No

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What colours are they? How many do you have?

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3.4 Smoking

Smoking and vaping will expose you to multiple metals

Do you/ did you smoke or vape?

Yes
No

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If so how many per day and for how long?

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3.5 Jewellery and cosmetics

Have you had any adverse reactions to pierced ears or other piercings ?

Yes
No

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What was the reaction? Was a particular metal problematic? eg nickel, silver, gold

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Does your skin become irritated/develop rashes when in contact with jeans buttons, watches rings or metals from zips and hook fastenings?

Yes
No

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Please give details

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Most brands of cosmetics contain metals. Do you use cosmetics?

Yes
No

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Does your skin react badly to any cosmetics?

Yes
No

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How often and which brands?

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Please give details of your symptoms

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What brand of toothpaste do you use? Most toothpastes contain titanium dioxide as a whitening agent

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3.6 Diet

Certain foods are high in nickel, fish from polluted sources may be high in mercury and titanium dioxide is used in some foods to brighten its appearance

Do you eat fish and seafood?

Yes
No

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What kind and how often?

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Do you eat crunchy-coated or multi-colored confectionery (eg M&Ms or doughnuts)?

Yes
No

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If yes, what brand and how often do you eat it?

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Do you chew gum frequently?

Yes
No

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3.7 Additional exposure

Some brands of nose and eye drops use thimerosal, a mercury containing substance as a preservative. Some contact lens solutions also contain thimerosal. Vaccines may contain aluminium as an adjuvant. None of the COVID-19 vaccines contain either thimerosal or aluminium as of May 2021

Do you / have you frequently used eye or nose drops that are NOT single use?

Yes
No

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Have you ever received a flu vaccine?

Yes
No

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Have you had an adverse reaction to vaccines in the past?

Yes
No

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Which vaccine and what was the reaction?

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4. Patch testing

Some dermatologists and allergists use patch testing to diagnose metal hypersensitivity though it may have irritative side effects

Have you had patch testing?

Yes
No

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Date of testing

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Test results

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Did you experience any changes in your health following patch testing?

Yes
No

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What were your symptoms?

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5. Your home

Some areas are more polluted than others and may have higher levels of metal vapours

Do you live near any of the following

Other

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6. For women

Have you ever had breast implants?

Yes
No

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Did you experience any symptoms post surgery?

Yes
No

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Which type of implants?

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Have you ever used an IU/sterilisation device containing metals? eg Essure, Copper 7, Hulka or Filshie clips etc

Yes
No

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Please specify the name of the device and your symptoms if any

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If you have given birth. Do you belong to the RH-negative blood group?

Yes
No

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Did you receive anti-RH-globulin after delivery?

Yes
No

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Which year?

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7. Allergies

Are you allergic to any antibiotics - penicillin, sulpha etc?

Yes
No

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Which one/s?

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Do you have any food allergies?

Yes
No

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Which foods?

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What are the symptoms?

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Do you have any other allergies?

Yes
No

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Please give details

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8. Your health

Do you have any diagnosed illnesses? Include autoimmune, cardio-vascular, skin disease, psychological illnesses

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Do you have any other symptoms which you feel are relevant?

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If you have had testing for Lyme disease and what was the result?

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Please list any reactions to electromagnetic fields, fluorescent tubes or chemical sensitivities

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9. Your family's health

Metal hypersensitivity appears to have a genetic component. Please include information about close relatives; parents, siblings or children (include grandparents and grandchildren if you consider necessary)

Allergies and automimmune disease

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Other

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10. Medication

Some medication may affect the MELISA blood test. Patients should not be taking any immune suppressive drugs such as steroids. Always check with the prescribing doctor before stopping any medication.

Type here

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11. Any additional information

The complex nature of metal allergies means it may manifest itself in ways not addressed by the above questions. If you have any unexplained symptoms, any other information you feel relevant, please detail as much as you can below..

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Type correct letters here(*)

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Online questionnaire

MELISA Questionnaire

1. Personal details

2. Your dental record

3. Metal exposure

3.1 Occupational Exposure

3.2 Tattoos

3.4 Smoking

3.5 Jewellery and cosmetics

3.6 Diet

3.7 Additional exposure

4. Patch testing

5. Your home

6. For women

7. Allergies

8. Your health

9. Your family's health

10. Medication

11. Any additional information

COPYRIGHT MELISA Diagnostics, May 2021