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Below is questionnaire which can identify those most likely to receive meaningful information from the MELISA® test. The evaluation will indicate if you already have symptoms suggestive of an allergy to dental metals, body implants or metals encountered in everyday life such as nickel. Please only fill it in if you have been in contact with a MELISA® laboratory or clinic/health care practitioner who is happy to receive this information from you and evaluate it. The MELISA® Medica Foundation is not able to answer all patient queries or give medical advice. The information you leave in this questionnaire will be held in strict confidence by the staff of MELISA® Medical Foundation.



Please fill the questionnaire and submit for evaluation.
Fields Marked with * are mandatory.
 Personal Details
Name *
Date of Birth
Address
Town & Country *
Telephone* & Fax
Email Address *
Occupation
Past Occupation
Diagnosed Disease If any
 1. Your Dental Record
Dental restorations are the most common causes of metal allergy; the more intimate exposure to metals such as mercury and gold, the greater the chance of becoming sensitised.
1.1 Your Current Dental Fillings
Dental material Year of placement: Number of fillings:
Amalgam
Gold Crowns
Titanium inlays, crowns
Composites
Metal-bound ceramic
Nickel-Cobalt-crown
Non-metallic ceramics
1.2 Root fillings
Dental material Year of placement: Number of fillings:
Amalgam
Gutta-percha
Calcium hydroxide
1.3 Do you have any other implants in your mouth?
Dental Material Year of Placement
Brånemark titanium with gold
Brånemark titanium only
Zirconium
Others Please Specify:
1.4 a) Are you wearing or have your ever worn dental braces?
1.4 b) Are you wearing or have your ever worn dentures?
1.5 Replacing dental fillings
Replacing fillings is a complicated process, and there is a danger that some of the metal being removed or put in to the teeth can be released into the mouth. This can kick-start metal allergy.
a) Have you had your dental fillings replaced?
 
b) Is the treatment complete or ongoing?
1.6 Which material did you change to?
Gold
Ceramics (porcelain)
Other 		Composite (plastic)
Metal-bound (MB) ceramic
Titanium Crowns
1.7 If you are in the process of changing your fillings, or have completed the treatment, did you feel any symptoms afterwards which you suspect may have been connected to the dental treatment?
1.8 Since replacing your fillings, have your health improved or got worse?
  Improved Worsened No real Change
1.9 Since the dental restoration, have you suffered from oral burning, itching or irritation of tissue inside your mouth?
1.10 Since the restoration, have you observed any new symptoms you did not have before, such as eczema, tiredness, etc?
 2. METAL EXPOSURE
Advances in science have introduced metals into a whole range of areas previously unthinkable from toothpaste to pacemakers inside the body. This section runs through some of the most common places metals are found.

2.1 Do you or did you have any metal in your body (implants, screws, pacemakers etc?)
If so, please specify
2.2 Do you have any tattoos?
2.3 Have you ever been exposed to heavy metals in the work place?
Workplace exposure to metals is a common cause of metal hypersensitivity. Please give this question some thought - it can include everything from factory work to being in regular contact with mercury-containing thermometers.
2.4 Do you eat a lot of fish and/or seafood?
2.5 SMOKING
a) Do you smoke or have you ever smoked?
b) Are you exposed to passive smoking at home or work?
2.6 VACCINES
Several vaccines contain metals, either as part of the preservative or as a residual trace from the production procedure. Manufacturers who use Thimerosal, for example, argue the mercury it contains is so small that it will not bring on a toxic effect. If you are hypersensitive, however, the smallest amount of mercury can trigger a lymphocyte reaction.
a) Have you ever been given a Gamma globulin vaccine?
This is often used prior to travel, or as a boost to the immune system
2.7 EYE DROPS/ NOSE DROPS
Some brands of eye and nose drops may contain thimerosal, a preservative which contains mercury		  
a) Do you or have you ever used eye or nose drops?
2.8 CONTACT LENSES
Some brands of contact lens solution may contain thimerosal		  
a) Do you use soft contact lenses?
2.9 COSMETICS
Most brands of make-up contain metal extracts of various kinds.		  
a) Do you use cosmetics?
b) Does your skin react badly to any cosmetics?
2.10 Have you ever been treated with colloidal gold or silver?
2.11 a) Do you wear earrings or piercing?
b) Do you experience discomfort with any of the following metals?
If so, with which materials do you notice the discomfort? (nickel, gold, silver, etc)
Nickel Gold Silver Other:
2.12 EVERYDAY ITEMS
Several confectionery (Smarties, Skittles etc) are coated with titanium to give them a crunchy coating. Most toothpastes also contain phosphate, which some people are hypersensitive to.
a)Do you use chewing gum?
b) Do you eat crunchy-coated or multi-colour confectionery?
c)Do you use toothpaste?
2.13 PATCH TEST FOR METAL ALLERGY
This is a form of metal allergy testing, but as it involves placing metal against the skin, it can have side-effects.
a) Have you ever done a skin test/patch test for metal allergy?
b) Did you experience any changes in your health status following skin testing?
2.14 Do you live, or have you ever lived, close to anywhere likely to exude amounts of metal vapour such as factories, industrial plants, freeways/motorways, airports, crematories and dental office?
  3. FOR WOMEN: (men go straight to section four)
3.1 Have you or have your ever had breast implants?
3.2 If you have given birth, did you receive anti-RH-globulin after delivery?
3.3 IU-devices

a)Have you ever used an IU device?
b) If so, have you experienced discomfort using the IU device?
  4. ALLERGIES AND ILLNESSES
4.1 Are you allergic to any antibiotics (penicillin, sulpha etc)?
4.2 Do you have other symptoms, which have not been clearly diagnosed? If so, please supply details
4.3 YOUR FAMILY HEALTH
Please give details if any members of your family suffer any of the following:
a) Allergies
b) Autoimmune diseases
c) Skin diseases
d) Heart/artery diseases
e) Diabetes
f) Cancer/tumors
g) Reactions to electro-magnetic fields
(such as photocopiers, microwave ovens, fluorescent tube lamps in shops)
h) Chemical sensitivity
i) Psychological illnesses
j) Other
Please provide details.
4.4 Are you currently taking any medication?
4.5 Do you take vitamin or mineral supplement?
 5. ANY OTHER INFORMATION
The complex nature of metal allergies mean it may manifest itself in ways not addressed by the above question. If you have any unexplained symptoms, any other information you feel is relevant or any personal suspicions on what may be behind your illness, please detail as much as you can below
Your submitted information will be treated confidentially
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