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Home
What We Do
Services
Clinical Nutrition
Chiropractic Care
Detoxification
Functional Blood Chemistry Analysis
Nutrition Response Testing
Quantum Neurology
Neurological Therapy
Emotional Freedom Technique
Homeopathy
NAET Therapy
Cardiovascular Services
Just Get Well
Testing
Detox
Phone/Teleheath Consult
Patient Forms
Blog
About Us
Meet The Team
New Patients
Contact
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Toxicity Questionnaire
Name
*
Date of Birth
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Date
Please rate each of the following based on your health profile based on the last 90 days:
0 = Rarely or never experience the symptom
1= Occasionally experience but effective is not severe
2 = Occasionally experience but effect is severe
3 = Frequently experience and effect is not severe
4 = Frequently experience and effect is severe
Heart
Shortness of Breath
0
1
2
3
4
Skipped/Rapid Heartbeat
0
1
2
3
4
High/Low Blood Pressure
0
1
2
3
4
Chest Pain
0
1
2
3
4
Tightness in Chest
0
1
2
3
4
Total Heart:
Price:
$0.00
Mouth, Throat, Teeth
Dry Mouth
0
1
2
3
4
Canker Sores
0
1
2
3
4
Cold Sores
0
1
2
3
4
Tooth Pain
0
1
2
3
4
Bleeding Gums
0
1
2
3
4
Gagging/Clearing Throat
0
1
2
3
4
Total For MTT:
Price:
$0.00
Skin, Hair, Nails
Flushing
0
1
2
3
4
Cold Hands/Feet
0
1
2
3
4
Acne
0
1
2
3
4
Dry Skin/Oily Skin
0
1
2
3
4
Hives/Rashes
0
1
2
3
4
Eczema, Psoriasis
0
1
2
3
4
Hair Loss
0
1
2
3
4
Cracked Heels on Feet
0
1
2
3
4
Bruising
0
1
2
3
4
Brittle Nails
0
1
2
3
4
Total Skin,Hair,Nails:
Price:
$0.00
Sleep
Can’t Fall Asleep
0
1
2
3
4
Wake Up Often
0
1
2
3
4
Nighttime Urination
0
1
2
3
4
Wake Up Tired
0
1
2
3
4
Bad Dreams/Nightmares
0
1
2
3
4
Night Sweats
0
1
2
3
4
Total Sleep:
Price:
$0.00
Lungs
Difficulty Breathing
0
1
2
3
4
Chest Congestion
0
1
2
3
4
Coughing
0
1
2
3
4
Asthma
0
1
2
3
4
Total Lungs:
Price:
$0.00
Digestive
Nausea
0
1
2
3
4
Diarrhea or Vomiting
0
1
2
3
4
Heartburn/Reflux
0
1
2
3
4
Straining on Bowel Mvmt
0
1
2
3
4
Day without Bowen Mvmt
0
1
2
3
4
Gas, Belch, Bloating
0
1
2
3
4
Hemorrhoids
0
1
2
3
4
Total Digestive:
Price:
$0.00
Allergies
Watery, Itchy Eyes
0
1
2
3
4
Runny Nose
0
1
2
3
4
Sneezing
0
1
2
3
4
Itchy Throat
0
1
2
3
4
Itchy Skin
0
1
2
3
4
Post Nasal Drip
0
1
2
3
4
Total Allergies:
Price:
$0.00
Head, Eyes
Blurred Vision
0
1
2
3
4
Pressure
0
1
2
3
4
Faintness
0
1
2
3
4
Dizziness
0
1
2
3
4
Headaches
0
1
2
3
4
Total Head,Eyes:
Price:
$0.00
Joint, Muscles, Bones
Twitching
0
1
2
3
4
Cramping
0
1
2
3
4
Stiffy & Achy Joints
0
1
2
3
4
Pain in Joints
0
1
2
3
4
Swelling in Joints
0
1
2
3
4
Muscle Aches
0
1
2
3
4
Muscle Pains
0
1
2
3
4
Osteoporosis
0
1
2
3
4
Numbness/Burning
0
1
2
3
4
Flat Feet/Fallen Arches
0
1
2
3
4
Total JMB:
Price:
$0.00
Ears, Sinus, Nose
Popping Ears
0
1
2
3
4
Fluid in Ears
0
1
2
3
4
Ringing in Ears
0
1
2
3
4
Hearing Loss
0
1
2
3
4
Ear Infections
0
1
2
3
4
Excessive Mucous
0
1
2
3
4
Stuffy Nose
0
1
2
3
4
Sinus Headache
0
1
2
3
4
Nose Bleeds
0
1
2
3
4
Total Ears,Sinus,Nose:
Price:
$0.00
Immune
Frequent Illness
0
1
2
3
4
Sore Throat
0
1
2
3
4
Fever
0
1
2
3
4
Genital Itch/Discharge
0
1
2
3
4
Yellow Nail Fungus
0
1
2
3
4
Total Immune:
Price:
$0.00
Urinary Tract
Frequent Urination
0
1
2
3
4
Burning on Urination
0
1
2
3
4
Dribbling Urine
0
1
2
3
4
Leaky Bladder
0
1
2
3
4
Blood in Urine
0
1
2
3
4
Kidney Stones
0
1
2
3
4
Total Urinary Tract:
Price:
$0.00
Energy
Fatigue/Tired
0
1
2
3
4
Sluggishness
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Restlessness
0
1
2
3
4
Brain Fog
0
1
2
3
4
Irritable if miss meals
0
1
2
3
4
Swelling hands & feet
0
1
2
3
4
Total Energy:
Price:
$0.00
Emotions
Mood Swings
0
1
2
3
4
Anxiety/Fear/Nervous
0
1
2
3
4
Anger/Irritability
0
1
2
3
4
Panic Attacks
0
1
2
3
4
Depression
0
1
2
3
4
Sense of Despair
0
1
2
3
4
Total Emotions:
Price:
$0.00
Hormones
Oily Skin, Acne
0
1
2
3
4
Pain during Period
0
1
2
3
4
Breast Tenderness
0
1
2
3
4
Irregular Cycle
0
1
2
3
4
Weight Gain
0
1
2
3
4
Cry Easily
0
1
2
3
4
Vaginal Dryness
0
1
2
3
4
Hot Flashes
0
1
2
3
4
Loss of Sex Drive
0
1
2
3
4
Erectile Dysfunction
0
1
2
3
4
Balding
0
1
2
3
4
Anger Easily
0
1
2
3
4
Total Hormones
Price:
$0.00
Total For All Sections:
$0.00
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