Toxicity Quiz

Total

Name*

First NameLast Name

Date*

Date

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Rate Each othe following based upon your health profile for the past 90 days

Select 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

Digestive*

	0	1	2	3	4
Nausea and/or vomiting
Diarrhea
Constipation
Bloated feeling
Belching and/or passing gas
Heartburn

Ears*

	0	1	2	3	4
Itchy ears
Earaches or ear infectons
Drainage from ear
Ringing in ears or hearing loss

Emotions*

	0	1	2	3	4
Mood swings
Anxiety, fear, or nervousness
Anger, irritability
Depression
Sense of despair
Uncaring or disinterested

Energy / Activity*

	0	1	2	3	4
Fatigue or sluggishness
Hyperactivity
Restlessness
Insomnia
Startled awake at night

Eyes*

	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Dark circles under eyes
Blurred or tunnel vision

Head*

	0	1	2	3	4
Headaches
Faintness
Dizziness
Pressure

Lungs*

	0	1	2	3	4
Chest congestion
Asthma or bronchitis
Shortness of breath
Difficulty breathing

Mind*

	0	1	2	3	4
Poor memory
Confusion
Poor concentration
Difficulty making decisions
Stuttering, stammering
Slurred speech
Learning disabilities

Mouth / Throat*

	0	1	2	3	4
Chronic coughing
Gagging or frequent need to clear throat
Swollen or discolored tongue, gums, lips
Canker sores

Nose*

	0	1	2	3	4
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucous

Skin*

	0	1	2	3	4
Acne
Hives, rashes or dry skin
Hair loss
Flushing
Excessive sweating

Heart*

	0	1	2	3	4
Skipped heartbeats
Rapid heartbeats
Chest Pain

Joints / Muscles*

	0	1	2	3	4
Pain or aches
Rheumatoid arthritis
Osteoarthritis
Stiffness or limited mobility
Pain or aches in muscles
Recurrent back aches
Feeling of weakness or tiredness

Weight*

	0	1	2	3	4
Binge eating or drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

Other*

	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Leaky bladder
Genital itch, discharge

Select the corresponding number for the following

0	Never
1	Rarely
2	Monthly
3	Weekly
4	Daily

Risk of exposure pt 1*

	0	1	2	3	4
How often are strong chemicals used in your home? (i.e. disinfectancts, bleach, oven/drain cleaners, furniture polish, floor wax, window cleaners etc.)
How often are pesticides used in your home?
How often do you have you home treated for insects?
How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish?
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?

Select the corresponding number for Risk of exposure pt 1 & pt 2

0	No
1	Mild change
2	Moderate Change
3	Drastic Change

Risk of exposure pt 2*

	0	1	2	3
Have you noticed any negative change in your health since you moved into your home or apartment?
Have you noticed any negative change to your health since you started your job

Yes or No Pt 1 *

	Yes	No
Do you have indoor pets?
Are you a dentist, painter, farm worker, or construction worker?

Yes or No Pt 2*

	Yes	No
Do you have a water purification system in your home?
Do you have an air purification system in your home?