Toxicity Questionnaire

The Toxicity Questionnaire is designed to aid the practitioner in assessing a patient’s or client’s potential need for a detoxification program.

Section I: Symptoms

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

Circle the corresponding number
0Rarely or Never Experience the Symptom1Occasionally Experience the Symptom, Effect is Not Severe
2Occasionally Experience the Symptom, Effect is Severe3Frequently Experience the Symptom, Effect is Not Severe
4Frequently Experience the Symptom, Effect is Severe

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
d.) 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
Section 1 Total: 0

Section II: Risk of Exposure

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

Circle the corresponding number for questions 16a-16f below
0Never1Rarely2Monthly3Weekly4Daily
16a.) How often are strong chemicals used in your home?
(Disinfectants, Bleaches, Oven and Drain Cleaners, Furniture Polish, Floor Wax, Window Cleaners, etc.)
16b.) How often are pesticides used in your home?
16c.) How often do you have your home treated for insects?
16d.) How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?
16e.) How often are you exposed to nail polish, perfume, hairspray, or other cosmetics?
16f.) How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?
16g.) How often do you consume nonorganic foods?
Circle the corresponding number for questions 17a-17b below
0No1Mild Change2Moderate Change3Drastic Change
17a.) Have you noticed any negative change in your health since you moved into your home or apartment?
17b.) Have you noticed any change in your health since you started your new job?
Answer yes or no and circle the corresponding number for questions 18a-18d below
18a.) Do you have a water purification system in your home?
18b.) Do you have any indoor pets?
18c.) Do you have an air purification system in your home?
18d.) Are you a dentist, painter, farm worker, or construction worker?
Section 2 Total: 0
Total: 0
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