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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