Toxicity Questionnaire

Section I: Symptoms

Rate each of the following based upon your health profile for the past 90 days.

0	Rarely or Never Experience the Symptom
1	Occasionally Experience the Symptom, Effect is Not Severe
2	Occasionally Experience the Symptom, Effect is Severe
3	Frequently Experience the Symptom, Effect is Not Severe
4	Frequently Experience the Symptom, Effect is Severe

Section II: Risk of Exposure

Rate each of the following situations based upon your environmental profile for the past 120 days.

0	Never
1	Rarely
2	Monthly
3	Weekly
4	Daily

Click the corresponding button.

0	No
1	Mild Change
2	Moderate Change
3	Drastic Change

Click yes or no button for questions below.

1. Digestive

a. Nausea and/or vomiting

b. Diarrhea

c. Constipation

d. Bloated feeling

e. Belching and/or passing gas

f. Heartburn

2. Ears

a. Itchy ears

b. Earaches or ear infections

c. Drainage from ear

d. Ringing in ears or hearing loss

3. Emotions

a. Mood swings

b. Anxiety, fear, or nervousness

c. Anger, irritability

d. Depression

e. Sense of despair

f. Uncaring or disinterested

4. Energy / Activity

a. Fatigue or sluggishness

b. Hyperactivity

c. Restlessness

d. Insomnia

e. Startled awake at night

5. Eyes

a. Watery or itchy eyes

b. Swollen, reddened, or sticky eyelids

c. Dark circles under eyes

d. Blurred or tunnel vision

6. Head

a. Headaches

b. Faintness

c. Dizziness

d. Pressure

7. Lungs

a. Chest congestion

b. Asthma or bronchitis

c. Shortness of breath

d. Difficulty breathing

8. Mind

a. Poor memory

b. Confusion

c. Poor concentration

d. Poor coordination

e. Difficulty making decisions

f. Stuttering, stammering

g. Slurred speech

h. Learning disabilities

9. Mouth / Throat

a. Chronic coughing

b. Gagging or frequent need to clear throat

c. Swollen or discolored tongue, gums, lips

d. Canker sores

10. Nose

a. Stuffy nose

b. Sinus problems

c. Hay fever

d. Sneezing attacks

e. Excessive mucous

11. Skin

a. Acne

b. Hives, rashes, or dry skin

c. Hair loss

d. Flushing

e. Excessive sweating

12. Heart

a. Skipped heartbeats

b. Rapid heartbeats

c. Chest pain

13. Joints / Muscles

a. Pain or aches in joints

b. Stiffness or limited movement

c. Pain or aches in muscles

d. Recurrent back aches

e. Feeling of weakness or tiredness

14. Weight

a. Binge eating or drinking

b. Craving certain foods

c. Excessive weight

d. Compulsive eating

e. Water retention

f. Underweight

15. Other

a. Frequent illness

b. Frequent or urgent urination

c. Leaky bladder

d. Genital itch, discharge

a. How often are strong chemicals used in your home?
(disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.)

b. How often are pesticides used in your home?

c. How often do you have your home treated for insects?

d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?

e. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics?

f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?

g. How often do you consume non-organic foods?

a. Have you noticed any negative change in your health since you moved into your home or apartment?

b. Have you noticed any change in your health since you started your new job?

a. Do you have a water purification system in your home?

Yes

b. Do you have any indoor pets?

Yes

c. Do you have an air purification system in your home?

Yes

d. Are you a dentist, painter, farm worker, or construction worker?

Yes

Upon submission of the form, you will be provided with your toxicity results. Please print your results and provide them to your health care professional for evaluation.

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Toxicity Questionnaire

Section I: Symptoms

Section II: Risk of Exposure

Click the corresponding button.

Click yes or no button for questions below.

1. Digestive

2. Ears

3. Emotions

4. Energy / Activity

5. Eyes

6. Head

7. Lungs

8. Mind

9. Mouth / Throat

10. Nose

11. Skin

12. Heart

13. Joints / Muscles

14. Weight

15. Other

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Toxicity Questionnaire

Section I: Symptoms

Section II: Risk of Exposure

Click the corresponding button.

Click yes or no button for questions below.

1. Digestive

2. Ears

3. Emotions

4. Energy / Activity

5. Eyes

6. Head

7. Lungs

8. Mind

9. Mouth / Throat

10. Nose

11. Skin

12. Heart

13. Joints / Muscles

14. Weight

15. Other

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