Toxicity Assessment

1

Do you experience any of the following head-based symptoms?* This field is required.Select all that apply

Headaches/Migraines

Dizziness/Faintness

Neck tension

Cloudy head

None of the above

2

Do you experience any of the following sinus-based symptoms?* This field is required.Select all that apply

Nasal congestion (stuffy nose)

Allergies (seasonal or daily)

Mucus

Sneezing

Nose blowing

None of the above

3

Do you experience any of the following eye-based symptoms?* This field is required.Select all that apply

Dark circles under eyes

Bags under eyes

Itchy eyes

Discharge or watery eyes

Blurred Vision

Crusted eyes upon waking

None of the above

4

Do you experience any of the following ear-based symptoms?* This field is required.Select all that apply

Itchy ears

Drainage or discharge from ears

Ringing in ears (Tinnitus)

Excessive wax build up

Blocked or muffled hearing

None of the above

5

Do you experience any of the following teeth-based symptoms?* This field is required.Select all that apply

Pain in gums or teeth

Bleeding gums

Silver fillings

None of the above

6

Do you experience any of the following mouth-based symptoms?* This field is required.Select all that apply

Canker sores

Cold sores (herpes virus)

Cracking on lips

Discolored lips

White films on lips after eating or upon waking

None of the above

7

Do you experience any of the following tongue-based symptoms?* This field is required.Select all that apply

Red dots on tongue

Sides of tongue have dents (scalloping)

White, yellow, or brown coating on tongue

Cracks or lines on tongue

None of the above

8

Do you experience any of the following gland-based symptoms?* This field is required.Select all that apply

Swollen lymph nodes (armpits, neck, groin)

Difficulty swallowing

Loss of voice

Swollen ankles or hands/wrists/fingers

None of the above

9

Do you experience any of the following breathing-based symptoms?* This field is required.Select all that apply

Chest tension

Inability to get enough air in

Chest congestion

Chronic cough

Clearing throat a lot

Voice hoarseness

None of the above

10

Do you experience any of the following weight-based symptoms?* This field is required.Select all that apply

Difficulty losing weight

Gaining weight easily

Feeling swollen or puffy

Retaining water

Binge or compulsive eating

None of the above

11

Do you experience any of the following joint/muscle-based symptoms?* This field is required.Select all that apply

Pain in joints

Muscle stiffness

Limited range of motion

Muscle weakness

Arthritis

None of the above

12

Do you experience any of the following skin-based symptoms?* This field is required.Select all that apply

Acne

Hairloss

Flushing/hot flashes

Dry, flaky skin

Excessive sweating

Hives or itchiness

Psoriasis, eczema, ringworm, or skin rashes

None of the above

13

Do you experience any of the following sleep-based symptoms?* This field is required.Select all that apply

Inability to fall asleep

Can't stay asleep/wake up frequently

Nightmares

Heart racing at night

Night sweats

None of the above

14

Do you experience any of the following energy-based symptoms?* This field is required.Select all that apply

Tired upon waking

Daytime or afternoon fatigue

General lack of energy

Apathy

Lack of ambition or drive

None of the above

15

Do you experience any of the following energy-based symptoms?* This field is required.Select all that apply

Hyperactivity (can't sit still)

Restlessness (Feeling uncomfortable with quiet)

Tapping feet or shaking legs when seated

Decreased libido or sexual function

None of the above

16

Do you experience any of the following digestive-based symptoms?* This field is required.Select all that apply

Feeling tired after meals (especially lunch)

Gas

Belching/burping

Heartburn or indigestion

None of the above

17

Do you experience any of the following digestive-based symptoms?* This field is required.Select all that apply

Diarrhea

Constipation

Stomach or intestinal pain

Nausea or vomiting

Stomach sticking out more as day progresses

None of the above

18

Do you experience any of the following mind-based symptoms?* This field is required.Select all that apply

Lack of concentration

Easily distracted or lose train of thought

Difficulty making decisions

Brain fog

None of the above

19

Do you experience any of the following mind-based symptoms?* This field is required.Select all that apply

Stuttering or difficulty putting sentences together

Uncoordination or dropping things

ADD/ADHD or learning disabilities

None of the above

20

Do you experience any of the following emotion-based symptoms?* This field is required.Select all that apply

Anxiety

Overwhelm

Irritability

Anger or rage

Dark thoughts

None of the above

21

Do you experience any of the following emotion-based symptoms?* This field is required.Select all that apply

Sad for no reason

Mood swings

Depression

High strung

Seasonal Affective Disorder (SAD)

None of the above

22

Do you experience any of the following immunity-based symptoms?* This field is required.Select all that apply

Frequent colds (more than 2-3 illnesses per year)

Allergies (environmental or non-fatal food sensitivities)

Pneumonia in the last 12 months

Diagnosed disease

Unexplained illness

None of the above

23

Do you experience any of the following immunity-based symptoms?* This field is required.Select all that apply

Frequent colds (more than 2-3 illnesses per year)

Allergies (environmental or non-fatal food sensitivities)

Pneumonia in the last 12 months

Diagnosed disease

Unexplained illness

None of the above

24

Total Score: