45 Day TBD Questionnaire

1

What category below includes your age?* This field is required.

Kids (12 months - 12 years)

Teens (13 years - 17 years)

Adult (18 years +)

2

1. Do you use dryer sheets, disinfectant spray, window cleaner, toilet bowl cleaner, furniture polish, antibacterial soaps and hand sanitizer, hairspray, hair dye, and paraben- or phthalate-containing shampoo, Room, furniture, and car freshening sprays, room, furniture, and car freshening sprays?

YESNO

3

2. Do you store your food in plastic containers, Styrofoam, or foil?

YESNO

4

3. Do you use commercial deodorant, makeup, body lotion, or paraffin wax/scented candles?

YESNO

5

4. Do you have silver amalgam fillings in your teeth?

YESNO

6

5. Do you drink unfiltered water?

YESNO

7

6. Do you eat fast food and/or get food to go?

YESNO

8

7. Do you eat out more than 2x a week or bite your nails?

YESNO

9

8. Do you crave carbs, salt, or sugar?

YESNO

10

9. Do you feel sluggish, or could you use a nap daily?

YESNO

11

11. Do you feel puffy or bloated?

YESNO

12

10. Have you had a recent increase in alcohol intake?

YESNO

13

12. Do you have trouble falling or staying asleep?

YESNO

14

13. Do you have gas (burping or farting after eating)?

YESNO

15

14. Are you forgetful or have brain fog?

YESNO

16

15. Do you have uncontrollable anger, moodiness, anxiousness?

YESNO

17

1. Does your teen use antibacterial soaps and hand sanitizer, hairspray, hair dye, and paraben- or phthalate-containing shampoo?

YESNO

18

2. Does your teen use commercial deodorant, makeup, and body lotion?

YESNO

19

3. Does your teen have silver amalgam fillings in your teeth?

YESNO

20

4. Does your teen drink unfiltered water?

YESNO

21

5. Does your teen eat fast food and/or get food to go?

YESNO

22

6. Does your teen eat out more than 2x a week or bite their nails?

YESNO

23

7. Does your teen crave carbs, salt, or sugar?

YESNO

24

8. Does your teen feel sluggish, or have excessive energy?

YESNO

25

9. Does your teen have a bloated stomach?

YESNO

26

10. Does your teen have trouble falling or staying asleep?

YESNO

27

11. Does your teen have gas (burping or farting after eating)?

YESNO

28

12. Is your teen forgetful or do they have brain fog?

YESNO

29

13. Does your teen have uncontrollable anger, moodiness, or anxiousness?

YESNO

30

1. Does your child have silver amalgam fillings in their teeth?

YESNO

31

2. Does your child drink unfiltered water?

YESNO

32

3. Does your child eat fast food or food to go?

YESNO

33

4. Does your child bite their nails?

YESNO

34

5. Does your child crave carbs, salt, or sugar?

YESNO

35

6. Does your child appear sluggish, or over-energetic?

YESNO

36

7. Does your child have a bloated stomach?

YESNO

37

8. Does your child have trouble falling or staying asleep?

YESNO

38

9. Does your child burp or fart after eating?

YESNO

39

10. Does your child have a hard time focusing?

YESNO

40

11. Does your child have uncontrollable anger, moodiness, or is anxious?

YESNO

41

Adult Results

42

Teen Results

43

Kids Results