Restore Your Health Online Cellular Toxicity Assessment

Name*

First NameLast Name

Email*

example@example.com

Date*

MonthDayYear

rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year.*

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
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 or return to sleep)
8. Sound in ears (ringing or hearing your heart beat)
9. Psychological symptoms (even thoughts of suicide)
10. Sensitivity to sound

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
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)

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
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****
5. Excessive thirst and/or frequent urination
6. Red eyes or blurred vision at times
7. Morning stiffness
8. Sensitivity to smells (chemicals such as petrochemicals, perfumes, air fresheners)
9. Chronic fatigue or non-restful sleep

Calculation

	rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Receive static shock more often & with more dramatic effect than normal
2. Trouble processing new information
3. Word reversal or trouble finding words
4. Sensitivity to touch
5. Short-term memory loss
6. Chronic sinus congestion
7. Dry non-productive cough
8. Muscle twitching
9. Excessive sweating (especially at night)

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Joint pain that is not necessarily true arthritis (can move from joint to joint)
2. Difficulty losing weight regardless of diet or exercise
3. Persistent fungal or viral infection (including athlete's foot, warts, jock itch, candida etc.)
4. Frequent illness, prolonged illness or sick days
5. Numbness or weakness in arms and legs
6. Headaches
7. Trouble adding or dividing numbers in your head
8. Fluctuating constipation and diarrhea
9. Stomach pain for no apparent reason
10. Appetite swings
11. Frequent muscle aches, cramps, unusual sharp sudden pains
12. Rashes or rosacea

Calculation

Section 1 Total

Please rate each of the following symptoms to the best of your ability based upon your typical health profile over the last 90 days (3 Months).*

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Nausea and/or vomiting
2. Diarrhea
3. Constipation
4. Bloated feeling
5. Belching and/or passing gas
6. Heartburn

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Itchy ears
2. Earaches or ear infections
3. Drainage from ear
4. Ringing in ears or hearing loss

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Mood swings
2. Anxiety, fear, or nervousness
3. Anger, irritability
4. Depression
5. Sense of despair
6. Uncaring or disinterested

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Fatigue or sluggishness
2. Hyperactivity
3. Restlessness
4. Insomnia
5. Startled awake at night

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Watery or itchy eyes
2. Swollen, reddened, or sticky eyelids
3. Dark circles under eyes
4. Blurred or tunnel vision

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Headaches
2. Faintness
3. Dizziness
4. Pressure

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Chest congestion
2. Asthma or bronchitis
3. Shortness of breath
4. Difficulty breathing

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Poor memory
2. Confusion
3. Poor concentration
4. Poor coordination
5. Difficulty making decisions
6. Stuttering, stammering
7. Slurred speech
8. Learning disabilities

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Chronic coughing
2. Gagging or frequent need to clear throat
3. Swollen or discolored tongue, gums, lips
4. Canker sores

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Stuffy nose
2. Sinus problems
3. Hay fever
4. Sneezing attacks
5. Excessive mucous

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Acne
2. Hives, rashes, or dry skin
3. Hair loss
4. Flushing
5. Excessive sweating

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Skipped heartbeats
2. Rapid heartbeats
3. Chest pain

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, severe	Frequently have it, mild	Frequently have it, severe
1. Pain or aches in joints
2. Stiffness or limited movement
3. Pain or aches in muscles
4. Recurrent back aches
5. Feeling of weakness or tiredness

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Binge eating or drinking
2. Craving certain foods
3. Excessive weight
4. Compulsive eating
5. Water retention
6. Underweight

Calculation

	Rarely or never had symptom	Occasionally have it, mild	Occasionally have it, servere	Frequently have it, mild	Frequently have it, severe
1. Frequent illness
2. Frequent or urgent urination
3. Leaky bladder
4. Genital itch, discharge

Calculation

Please rate each of the following symptoms to the best of your ability based upon your typical health profile over the last 120 days (4 Months)*

	Never	Rarely	Monthly	Weekly	Daily
1. How often are chemicals used in your home (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.)
2. How often are pesticides used in your home?
3. How often do you have your home treated for insects?
4. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home office?
5. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics?
6. How often are you exposed to diesel fumes, exhaust fumes , or gasoline fumes?
7. How often do you consume nonorganic foods?

Calculation

	No	Mild Change	Moderate Change	Drastic Change
1. Have you noticed any negative change in your health since you moved into your new home or apartment?
2. Have you noticed any change in your health since you started your new job?

Calculation

	Yes	No
Do you have a water purification system in your home?
Do you have any indoor pets?
Do you have an air purification system in your home?
Are you a dentist, painter, farm worker, or construction worker?

Calculation

Section 2 Total

Final Total

Now that you've completed your cellular assessment, your next step is to schedule a "no strings attached" brief consultation with Dr. Wild to discuss your results, what impact they may have on your health and longevity, and what you can do to improve them. Simply click on the SUBMIT button below and a member of our team will reach out to you shortly to book your FREE 15-minute Discovery Call as soon as possible.

Restore Your Health Online Cellular Toxicity Assessment

Section 1: Neurotoxicity (Brain and Nervous System) Evaluation

Section 2: General Toxic Exposure & Insult Evaluation