CIRS and BioToxins Questionnaire
CIRS is an acronym for Chronic Inflammatory Response Syndrome. CIRS occurs when we are exposed to biotoxins, we are immune compromised and we are HLA genotype carriers.
Have you ever had glandular fever /EBV that you are aware of?
Please Select
Yes
No
Have you ever been exposed to any of the following: Breast or silicone implants ? Tic Bite? Mould or a water damaged building?
Please Select
Yes
No
If you answered yes to the above - please write more information here: When the exposure may have occurred and whether you are still being exposed.
Do you or a family member have coeliac disease?
Please Select
Ye
No
Today's Date
*
-
Day
-
Month
Year
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Are you a current NatMed Patient?
*
Yes
No
Please tick if you have any of the below symptoms. Please tick the box even if you only semi-regularly experience the symptom.
Section #1
Fatigue
Section #2
Weakness
Decreased assimilation of new Ideas
Aches
Light Sensitivity
Section #3
Memory Impairment
Decreased Word Finding
Question #4
Difficulty Concentrating
Section #5
Joint Pain
Stiffness in the Morning
Cramps
Section #6
Tingling
Tremors
Unusual Pain
Unusual Skin Sensations
Section #7
Shortness of Breath
Sinus Congestion
Section #8
Cough
Excessive Thirst
Confusion
Section #9
Apetite Swings
Difficulty regulating body temperature
Increased urinary frequency
Section #10
Red Eyes
Blurred Vision
Night Sweats
Mood Swings
Ice-Pick Pains
Section #11
Abdominal Pain
Diarrhoea
Numbness
Section #12
Tearing of Eyes
Disorientation
Metallic Taste
Section #13
Static Shocks
Vertigo
Number of Boxes Ticked:
Number of Sections that you have ANY ticked boxes
OutComes
A score of 8 or more of the 13 sections is considered diagnostic (98.4% sensitivity in adults)
Please let us know a little bit about your story here. How long you have been ill, whether you understand CIRS or Lyme disease and what you might be hoping I can do for you.
Save
Submit
Thank you. I am proud to support you on your journey to empower you to create the health you deserve.
Deborah Taylor - Naturopath for over 25 years, Chronic health, CIRS and Cancer support.
Want to know more about the condition we're screening for with this questionnaire? Read more on our dedicated CIRS page here: https://natmed.com.au/cirs/
Should be Empty: