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 | |||
|---|---|---|---|
| 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 | ||
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 | |||||||||
|---|---|---|---|---|---|---|---|---|---|
| 0 | Never | 1 | Rarely | 2 | Monthly | 3 | Weekly | 4 | Daily |
| 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 | |||||||
|---|---|---|---|---|---|---|---|
| 0 | No | 1 | Mild Change | 2 | Moderate Change | 3 | Drastic 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 |
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