Quick Environmental Exposure and Sensitivity Inventory

This validated questionnaire, The Quick Environmental Exposure and Sensitivity Inventory, or QEESI©, also known as the "TILT Test," helps researchers, doctors, and their patients identify individuals with multiple chemical intolerances. The QEESI© involves personal health information. Its use should be restricted to patients, their personal physicians, and researchers using the QEESI© as part of a protocol approved by an appropriate institutional review board (such as one registered with the U.S. Department of Health and Human Services Office for Human Research Protections).

This validated questionnaire, The Quick Environmental Exposure and Sensitivity Inventory, or QEESI©, also known as the "TILT Test," helps researchers, doctors, and their patients identify individuals with multiple chemical intolerances. The QEESI© involves personal health information. Its use should be restricted to patients, their personal physicians, and researchers using the QEESI© as part of a protocol approved by an appropriate institutional review board (such as one registered with the U.S. Department of Health and Human Services Office for Human Research Protections).

How to Use the QEESI

Please do not re-post the QEESI© or its image on any websites without written permission.

Doctors
This instrument is provided free of charge. Please do not charge patients for its use. Physicians are encouraged to use the QEESI©, as part of their clinical practice with patients when chemical intolerance or TILT (Toxicant-induced Loss of Tolerance) is suspected.

Patients
Patients are welcome to download and complete the QEESI©, and are encouraged to take it and the interpretation sheet to their doctors.

Researchers
Researchers must contact Dr. Claudia Miller for permission to use the QEESI© in their studies.

Contact
Dr. Claudia Miller, Professor
Department of Family & Community Medicine
University of Texas School of Medicine at San Antonio
7703 Floyd Curl Drive
San Antonio, TX 78229-3900
Main: (210) 562-6550
Fax: (210) 562-6552
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Additional information is available at www.drclaudiamiller.com.

Dr. Miller is not available to consult on individual cases or to serve as an expert witness.

About the QEESI

The Quick Environmental Exposure and Sensitivity Inventory (QEESI©) was developed as a screening questionnaire for multiple chemical intolerances (MCI). The instrument has four scales: Symptom Severity, Chemical Intolerances, Other Intolerances, and Life Impact. Each scale contains 10 items, scored from 0 = “not a problem” to 10 = “severe or disabling problem.” A 10-item Masking Index gauges ongoing exposures that may affect individuals’ awareness of their intolerances as well as the intensity of their responses to environmental exposures. Potential uses for the QEESI© include:

  1. Research—to characterize and compare study populations, and to select subjects and controls.
  2. Clinical evaluations—to obtain a profile of patients’ self-reported symptoms and intolerances. The QEESI© can be administered at intervals to follow symptoms over time or to document responses to treatment or exposure avoidance.
  3. Workplace or community investigations—to identify and assist those who may be more chemically susceptible or who report new intolerances. Affected individuals should have the option of discussing results with investigators or their personal physicians.

Individuals whose symptoms began or intensified following a particular exposure event can fill out the QEESI© using two different ink colors, one showing how they were before the event, and the second how they have been since the event. On the cover of the QEESI© is a “Symptom Star” (Figure 1) which provides a graphical representation of patients’ responses on the Symptom Severity Scale. (consider a symptom star automated with a two surveys)

Figure 1. QEESI Symptom Star illustrating symptom severity in an individual before and after an exposure event (e.g., pesticide application, indoor air contaminants, chemical spill)

Symptom Star

Interpreting the QEESI

In a study of 421 individuals, including four exposure groups and a control group, the QEESI© provided sensitivity of 92% and specificity of 95% in differentiating between persons with multiple chemical intolerances (MCI) and the general population (Miller and Prihoda 1999a,b).

Cronbach’s alpha reliability coefficients for the QEESI©’s four scales—Symptom Severity, Chemical Intolerances, Other Intolerances and Life Impact—were high (0.76-0.97) for each of the groups, as well as over all subjects, indicating that the questions on the QEESI© form scales showing good internal consistency. Pearson correlations for each of the four scales with validity items of interest, i.e., life quality, health status, energy level, body pain, ability to work and employment status, were all significant and in the expected direction, thus supporting good construct validity.

Information on the development of this instrument, its interpretation, and results for several populations have been published (Miller and Prihoda 1999a,b). Proposed ranges for the QEESI©’s scales and guidelines for their interpretation appear in Tables 1 and 2 below:

Table 1. Criteria for low, medium, and high scale scores

 Score
Scale/IndexLowMediumHigh
Symptom Severity 0-19 20-39 40-100
Chemical Intolerance 0-19 20-39 40-100
Other Intolerance 0-11 12-24 25-100
Life Impact 0-11 12-23 24-100
Masking Index 0-3 4-5 6-10


Table 2. Distribution of subjects by group using "high" cutoff points for symptom severity (≥ 40) and chemical intolerances (≥ 40), with masking low or not low (< 4 or ≥ 4)

2a. Risk Criteria1
Degree to Which MCI is Suggested2Symptom Severity ScoreChemical Intolerance ScoreMasking Score
Very suggestive ≥ 40 ≥ 40 ≥ 4
Very suggestive ≥ 40 ≥ 40 < 4
Somewhat suggestive ≥ 40 < 40 ≥ 4
Not suggestive ≥ 40 < 40 < 4
Problematic < 40 ≥ 40 ≥ 4
Problematic < 40 ≥ 40 < 4
Not suggestive < 40 < 40 ≥ 4
Not suggestive < 40 < 40 < 4
2b. Percentage of Each Group Meeting Risk Criteria
Controls n=76MCS - No Event n=90MCS - Event n=96Implant n=87Gulf War Veterans n=72
7 16 23 39 45
0 65 66 36 4
3 1 2 16 26
0 0 2 3 6
7 3 1 1 0
3 13 4 2 0
68 1 0 2 18
12 1 2 1 1
100 100 100 100 100

1 Subjects must meet all three criteria, i.e., Symptom Severity, Chemical Intolerance, and Masking scores, as indicated in each row of this table.
2 “Very suggestive” = high symptom and chemical intolerance scores.
“Somewhat suggestive” = high symptom score but possibly masked chemical intolerance.
“Not suggestive” = either (1) high symptom score but low chemical intolerance score with low masking, or (2) low symptom and chemical intolerance scores.
“Problematic” = low symptom score but high chemical intolerance score. Persons in this category with low masking (<4) may be sensitive individuals who have been avoiding chemical exposures for an extended period (months or years).

References

References:
Miller CS, Prihoda TJ: The Environmental Exposure and Sensitivity Inventory (EESI): a standardized approach for measuring chemical intolerances for research and clinical applications. Toxicology and Industrial Health 15:370-385, 1999a.

Miller CS, Prihoda TJ: A controlled comparison of symptoms and chemical intolerances reported by Gulf War veterans, implant recipients and persons with multiple chemical sensitivity. Toxicology and Industrial Health 15:386-397, 1999b.

Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes.
Katerndahl DA, Bell IR, Palmer RF, Miller CS.
Ann Fam Med. 2012 Jul-Aug;10(4):357-65. doi: 10.1370/afm.1346.
PMID: 22778124

Evaluation of the quick environmental exposure and sensitivity inventory in a Danish population.
Skovbjerg S, Berg ND, Elberling J, Christensen KB.
J Environ Public Health. 2012;2012:304314. doi: 10.1155/2012/304314. Epub 2012 Jan 12.
PMID: 22529872

Factors in genetic susceptibility in a chemical sensitive population using QEESI©.
Fujimori S, Hiura M, Yi CX, Xi L, Katoh T.
Environ Health Prev Med. 2012 Sep;17(5):357-63. doi: 10.1007/s12199-011-0260-8. Epub 2011 Dec 29. PMID: 22205546

Evaluation of subjective symptoms of Japanese patients with multiple chemical sensitivity using QEESI©.
Hojo S, Sakabe K, Ishikawa S, Miyata M, Kumano H.
Environ Health Prev Med. 2009 Sep;14(5):267-75. doi: 10.1007/s12199-009-0095-8. Epub 2009 Jul 15. PMID: 19603254 [PubMed]

The idiopathic environmental intolerance symptom inventory: development, evaluation, and application.
Andersson MJ, Andersson L, Bende M, Millqvist E, Nordin S.
J Occup Environ Med. 2009 Jul;51(7):838-47. doi: 10.1097/JOM.0b013e3181a7f021. PMID: 19542897

Evaluation of a Swedish version of the Quick Environmental Exposure and Sensitivity Inventory.
Nordin S, Andersson L.
Int Arch Occup Environ Health. 2010 Jan;83(1):95-104. doi: 10.1007/s00420-009-0427-4. Epub 2009 May 26. PMID: 19468745

[Diagnosis of multiple chemical sensitivity by chemical compounds exposure tests].
Hasegawa M, Ohtomo M, Mizuki M, Akiyama K.
Arerugi. 2009 Feb;58(2):112-8. Japanese. PMID: 19329873

[Questionnaire survey of workers in specific buildings regarding multiple chemical sensitivity].
Manabe R, Kunugita N, Katoh T, Kuroda Y, Akiyama Y, Yamano Y, Uchiyama I, Arashidani K.
Nihon Eiseigaku Zasshi. 2008 Jul;63(4):717-23. Japanese. PMID: 18840946

Clinical characteristics of physician-diagnosed patients with multiple chemical sensitivity in Japan.
Hojo S, Ishikawa S, Kumano H, Miyata M, Sakabe K.
Int J Hyg Environ Health. 2008 Oct;211(5-6):682-9. Epub 2007 Dec 21. PMID: 18155642

[Multiple chemical sensitivity: study of 52 cases].
Nogué S, Fernández-Solá J, Rovira E, Montori E, Fernández-Huerta JM, Munné P.
Med Clin (Barc). 2007 Jun 16;129(3):96-8; quiz 99. Spanish. PMID: 17594860

Application of Quick Environment Exposure Sensitivity Inventory (QEESI) for Japanese population: study of reliability and validity of the questionnaire.
Hojo S, Kumano H, Yoshino H, Kakuta K, Ishikawa S.
Toxicol Ind Health. 2003 Jul;19(2-6):41-9. PMID: 15697173