Toxicity Questionnaire

What types of toxins might be affecting you?

Not only does what we put into our bodies make a difference on our mood, energy and overall health, but environmental exposure to various pollutants also play a big role. You never know what’s being absorbed by our largest organ–our skin–and from what we inhale on a daily basis.

This Toxicity Questionnaire will walk you through many questions that reflect how you may be responding to these outside stressors.

Toxicity Questionnaire

SECTION 1: Symptoms Choose the best corresponding number for the questions below. 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

DIGESTION

Nausea and/or vomiting *
Diarrhea *
Constipation *
Bloated feeling *
Belching and/or passing gas *
Heartburn *

EARS

Earaches or ear infection *
Itchy ears *
Ear drainage *
Ringing in ears or hearing loss *

EMOTIONS

Mood swings *
Anxiety, fear or nervousness *
Anger, irritability *
Depression *
Sense of despair *
Uncaring or disinterested *

ENERGY / ACTIVITY

Fatigue or sluggishness *
Restlessness *
Hyperactivity *
Insomnia *
Startled awake at night *

EYES

Watery or itchy eyes *
Swollen, reddened or sticky eyelids *
Dark circles under eyes *
Blurred or tunnel vision *

HEAD

Headaches *
Faintness *
Dizziness *
Pressure behind eyes *

LUNGS

Chest congestion *
Asthma or bronchitis *
Shortness of breath *
Difficulty breathing *

MIND

Poor memory *
Confusion *
Poor concentration *
Difficulty making decisions *
Stuttering, stammering *
Learning disabilities *
Slurred speech *
Poor concentration *

MOUTH / THROAT

Chronic coughing *
Gagging or frequent need to clear throat *
Swollen or discolored tongue, gums or lips *
Canker sores *

SINUS

Stuffy nose *
Sinus problems *
Hay fever *
Sneezing attacks *
Excessive mucous *

SKIN

Acne *
Hives, rashes or dry skin *
Hair loss *
Flushing *
Excessive sweating *

HEART

Skipped heartbeats *
Rapid heartbeats *
Chest pain *

JOINTS / MUSCLES

Pain or aches in joints *
Rheumatoid arthritis *
Osteoarthritis *
Stiffness or limited movement *
Pain or aches in muscles *
Recurrent back aches *
Feeling of weakness or tiredness *

WEIGHT

Binge eating or drinking *
Craving certain foods *
Excessive weight *
Compulsive eating *
Water retention *
Underweight *

OTHER

Frequent illness *
Frequent or urgent urination *
Leaky bladder *
Genital itching, discharge *

SECTION 2: Risk of Exposure

Choose the best corresponding number for the questions below.
How often are strong chemicals used in your home? (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.) *
How often are pesticides used in your home? *
How often do you have your home treated for insects? *
How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense or varnish in your home or office? *
How often are you exposed to nail polish, perfume, hairspray or other cosmetics? *
How often are you exposed to diesel fumes, exhaust fumes or gasoline fumes? *
Choose the best answer for the questions below.
Have you noticed any negative change in your health since you moved into your home or apartment? *
Have you noticed any change in your health since you started your new job? *
Do you have a water purification system in your home? *
Do you have any indoor pets? *
Do you have an air purification system in your home? *
Are you a dentist, painter, farm worker, or construction worker? *
Section 2 Total: Add up all your numbers for a grand total. What is your total for section 2? *

GRAND TOTAL

Add the totals for each section to arrive at a grand total and write it below. If any INDIVIDUAL section total is 6 or more, or the GRAND total is 40 or more, you may benefit from my body cleaning program. *
How did you feel when you answered the questions here? Did it bring about an awareness in any particular areas? Please share your comments below. Thank you. *
Name: *
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Eat smart • Move more • Feel better • Live longer

Toxicity Questionnaire

What types of toxins might be affecting you?

Toxicity Questionnaire

DIGESTION

EARS

EMOTIONS

ENERGY / ACTIVITY

EYES

HEAD

LUNGS

MIND

MOUTH / THROAT

SINUS

SKIN

HEART

JOINTS / MUSCLES

WEIGHT

OTHER

SECTION 2: Risk of Exposure

GRAND TOTAL

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