TOXICANTS AND TOXINS

Toxicity Questionnaire

In each box below enter the number that corresponds with your choice. (0 = Never, 1 = Occasionally, 2 = Often, 3 = Regularly)

Please note some questions in this section may have different scoring which will be written next to it in the following format (No=X, Yes=X).

Live on or near a golf course? (No=0 Yes=4)

Excessive perspiring during day or night

Live near a freeway or high-tension wires? (No=0 Yes=4)

Cold extremities (hands and feet)

Wear conventional sunscreen? (No=0 Yes=4)

Issues processing new information

Wear perfume or cologne? (No=0 Yes=4)

Chronic fungal or viral infection, including Candida, foot fungus, warts, or jock itch

Use air fresheners in your house, car, or workplace? (No=0 Yes=4)

Get sick often

Were you the first-born child? (No=0 Yes=4)

Weakness or numbness in extremities

Receive static shocks (doorknob, car, light switch, other people, etc.)

Joint pain

Headaches or migraines

Muscle cramps, aches, sharp pains

Word reversal or trouble finding words

Muscle twitching

Sensitivity to skin or touch

Stomach pain

Poor short-term memory

Appetite swings

Chronic sinus issues or congestion

Rashes or rosacea

Difficulty losing weight regardless of diet or exercise

Toxicity Total _________

Risk for Toxicity:

Low = 0-19, Medium = 20-50, High = 51-81