Neurotoxic Questionnaire
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Section 1: Heavy Metals
Rate each of the following symptoms to the best of your ability based on your typical day over the past year.
*
Never Experienced
Occasionally have it, mild effect
Occasionally have it, severe effect
Frequently have it, mild effect
Frequently have it, severe effect
Anxiety
Mood Swings
Enraged Behavior or Anger
Excessive Shyness, Timidity, Social Phobia
Irritability
Low Body Temperaure (below 97.3)
Insomnia
Dizziness
Sound in Ears (ringing or heart beat)
Psycholotical Symptoms, Thoughts of Suicide
Sensitivity to Sound
Total Secion 1:
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Section 2: Chemical Toxins
Rate each of the following symptoms to the best of your ability based on your typical day over the past year.
*
Never Experienced
Occasionally have it, mild effect
Occasionally have it, severe effect
Frequently have it, mild effect
Frequently have it, severe effect
Indecisiveness
Feeling of Being Overwhelmed or Fearful
Metallic Taste in Your Mouth
Bad Breath
Bleeding Gums
Sensitive Teeth
Canker Sores or Other Sores in the Mouth
Floaters, Shadows, or Swimmers When You Read or Look Into the Sky
Dyslexia or Loss of Place While Reading, Even as a Child
Swelling Eyelids
Peeling on Top Layer of Skin (hands,feet)
Dry Skin
Heart Pain and You're Under 45 Years Old
Depression
Gout (arthritic pain, especially in big toes)
Pain in Shoulders or Upper Back
Twitching Eyelids
Anemia
Wrist/Andle Drop or Weak Extensor Muscles
Hair Falls Out Excessively
Total Section 2:
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Section 3: Biotoxins/Mycotoxins
Rate each of the following symptoms to the best of your ability based on your typical day over the past year.
*
Never Experienced
Occasionally have it, mild effect
Occasionally have it, severe effect
Frequently have it, mild effect
Frequently have it, severe effect
Sensitivity to Light
Fatigue After Exercising (feeling worse)
Bad Night Vision or Seeing Halos Around Lights
Shortness of Breath with Very Little Effort
Excessive Thirst and/or Frequent Urination
Red Eyes or Tearing
Blurred Vision at Times
Morning Stiffness
Sensitivity to Chemial Smells
Chronic Fatigue or Weakness
Non-Restful Sleep
Total Section 3:
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Section 4: Combination of Heavy Metals and Toxic Chemicals
Rate each of the following symptoms to the best of your ability based on your typical day over the past year.
*
Never Experienced
Occasionally have it, mild effect
Occasionally have it, severe effect
Frequently have it, mild effect
Frequently have it, severe effect
Receive Static Shock More Often & with More Dramatic Effect than Normal
Trouble Processing New Information
Word Reversal or Trouble Finding Words
Sensitivity to Touch
Short-Term Memory Loss
Chronic Sinus Congestion
Dry Non-Productive Cough
Muscle Twitching
Excessive Sweating, Especially at Night
Joint Pain - Not Necessarily True Arthritis - Can Move from Joint to Joint
Difficulty Losing Weight Regardless of Diet or Exercise
Persistent Fungal or Viral Infection, Including Athlete's Foot, Warts, Candida
Frequent Illness, Prolonged Illness or Sick Days
Numbness or Weakness in Arms and Legs
Headaches
Trouble Adding or Dividing Numbers in Your Head
Fluctuating Diarrhea and Constipation
Stomach Pain for No Apparent Reason
Appetite Swings
Frequent Muscle Aches, Cramps, Unusual Sharp Sudden Pains
Rashes or Rosacea
Cold Extremities (hands and feet)
Total Secion 4:
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Total Neurotoxic Score:
Scoring over 100: Severely neurotoxic; you are positive for neurotoxicity and undoubtedly need The Explant Reset Program Scoring: 50-100: Moderate neurotoxicity; you are positive for neurotoxicity and need The Explant Reset Program to decrease symptoms and improve overall health. Less than 50: less toxic; you should still do The Explant Reset Program to increase vitality due to the ubiquitous neurotoxins in our modern world.
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