Cellular Toxicity Questionnaire (CTQ)

Cellular Toxicity Questionnaire (CTQ)

Please be as accurate as possible and write down your overall score to discuss with your coach once complete.
Name*

First NameLast Name
Phone Number

Area CodePhone Number
Step 1. All about you
The purpose of this questionnaire is to serve you at the highest level on our next call. Your time is valuable, as is mine, so please be honest with your answers so I can serve you towards creating the best possible results in your fitness, body, and life.

Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply select the most likely answer or the "Not at all" option.*

Rows	Not at all-0	Mild effect -1	Frequent, mild effect-2	Severe effect-3
1. Anxiety
2. Mood swings
3. Enraged behavior or anger
4. Excessive shyness, timidity, social phobia (not typical to your personality)
5. Irritability (not typical to your personality)
6. Low body temperature (below 97.3 F)
7. Insomnia (can’t get to sleep or return to sleep)
8. Dizziness
9. Sound in ears (ringing or hearing your heart beat)
10. Psychological symptoms, even thoughts of suicide
11. Sensitivity to sound

Section Total

Section 2*

Rows	Not at all-0	Mild effect -1	Frequent, mild effect-2	Severe effect-3
1. Indecisiveness
2. Feeling of being overwhelmed or fearful
3. Metallic taste in your mouth
4. Bad breath
5. Bleeding gums
6. Sensitive teeth
7. Canker sores or other sores in the mouth
8. Floaters, shadows or swimmers when you read or look into the sky
9. Dyslexia or loss of place while reading, even as a child
10. Swelling eyelids
11.Peeling on the top layer of skin (hands, feet)
12. Dry skin
13. Heart pain (angina) and you are under 45 years old
14. Depression
15. Gout (arthritic pain, especially in big toes)
16. Pain in shoulders or upper back
17. Twitching eyelids
18. Anemia
19. Wrist/ankle drop or weak extensor muscles
20. Hair falls out (not normal male pattern baldness)

Section Total

Section 3*

Rows	Not at all-0	Mild effect -1	Frequent, mild effect-2	Severe effect-3
1. Sensitivity to light
2. Fatigue after exercising (feeling worse)
3. Bad night vision or seeing halos around lights
4. Shortness of breath, with very little effort
5.Excessive thirst and/or frequent urination
6. Red eyes or tearing
7. Blurred vision at times
8. Morning stiffness
9. Sensitivity to smells (chemicals such as petrochemicals, perfumes, air fresheners)
10. Chronic fatigue or weakness
11. Non-restful sleep

Section Total
Total Score

Cellular Toxicity Questionnaire (CTQ)

Step 1. All about you