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Toxicity Questionnaire
Name
Date of Birth
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
Skipped/Rapid Heartbeat
High/Low Blood Pressure
Chest Pain
Tightness in Chest
Price: $0.00
Mouth, Throat, Teeth
Dry Mouth
Canker Sores
Cold Sores
Tooth Pain
Bleeding Gums
Gagging/Clearing Throat
Price: $0.00
Skin, Hair, Nails
Flushing
Cold Hands/Feet
Acne
Dry Skin/Oily Skin
Hives/Rashes
Eczema, Psoriasis
Hair Loss
Cracked Heels on Feet
Bruising
Brittle Nails
Price: $0.00
Sleep
Can’t Fall Asleep
Wake Up Often
Nighttime Urination
Wake Up Tired
Bad Dreams/Nightmares
Night Sweats
Price: $0.00
Lungs
Difficulty Breathing
Chest Congestion
Coughing
Asthma
Price: $0.00
Digestive
Nausea
Diarrhea or Vomiting
Heartburn/Reflux
Straining on Bowel Mvmt
Day without Bowen Mvmt
Gas, Belch, Bloating
Hemorrhoids
Price: $0.00
Allergies
Watery, Itchy Eyes
Runny Nose
Sneezing
Itchy Throat
Itchy Skin
Post Nasal Drip
Price: $0.00
Head, Eyes
Blurred Vision
Pressure
Faintness
Dizziness
Headaches
Price: $0.00
Joint, Muscles, Bones
Twitching
Cramping
Stiffy & Achy Joints
Pain in Joints
Swelling in Joints
Muscle Aches
Muscle Pains
Osteoporosis
Numbness/Burning
Flat Feet/Fallen Arches
Price: $0.00
Ears, Sinus, Nose
Popping Ears
Fluid in Ears
Ringing in Ears
Hearing Loss
Ear Infections
Excessive Mucous
Stuffy Nose
Sinus Headache
Nose Bleeds
Price: $0.00
Immune
Frequent Illness
Sore Throat
Fever
Genital Itch/Discharge
Yellow Nail Fungus
Price: $0.00
Urinary Tract
Frequent Urination
Burning on Urination
Dribbling Urine
Leaky Bladder
Blood in Urine
Kidney Stones
Price: $0.00
Energy
Fatigue/Tired
Sluggishness
Hyperactivity
Restlessness
Brain Fog
Irritable if miss meals
Swelling hands & feet
Price: $0.00
Emotions
Mood Swings
Anxiety/Fear/Nervous
Anger/Irritability
Panic Attacks
Depression
Sense of Despair
Price: $0.00
Hormones
Oily Skin, Acne
Pain during Period
Breast Tenderness
Irregular Cycle
Weight Gain
Cry Easily
Vaginal Dryness
Hot Flashes
Loss of Sex Drive
Erectile Dysfunction
Balding
Anger Easily
Price: $0.00
$0.00

These claims/statements have not been evaluated by the Food and Drug Administration (FDA). This product is not intended to diagnose, treat, cure, or prevent any disease.
Living Well Clinical Nutrition Center is authorized to sell Standard Process Products, but is not a partner, franchisor, joint venturer, agent, or employee of Standard Process Inc.

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Our team at Living Well consists of Doctor’s of Chiropractic, Clinical Nutritionists, Clinical Massage Therapists, NET & NAET Clinicians, and a full team of smiles ready to serve you on your wellness journey.
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