Neurotoxicity Questionnaire

1

First, let's get some basic info about you. Don't worry, this information is for Dr. Effertz' eyes only and will never be shared or sold...

2

What is your first name?* This field is required.

3

And your last name?* This field is required.

4

Please confirm the email address you used to schedule your consultation with a health expert from Dr. Effertz's team.* This field is required.

example@example.com

5

Thanks. What phone number did you use for your appointment?* This field is required.

Please enter a valid phone number.

6

Date of Birth?* This field is required.

7

And are you male or female?* This field is required.

Male

Female

8

Height* This field is required.

9

Weight* This field is required.

10

Please list current medications* This field is required.

11

Please list current supplements* This field is required.

12

Please list top 4 or 5 symptoms* This field is required.

13

What are your top challenges with your health?* This field is required.

14

Do you have any official medical diagnoses? (Current and/or Resolved)

YESNO

15

Please list any official medical diagnoses, current and resolved, along with the year each was diagnosed (if known).* This field is required.

16

Please list your surgical history, if any.* This field is required.

17

Please list any active treatment plans you have in place.* This field is required.

18

What else have you tried to help improve your health?* This field is required.

19

What specifically are you trying to achieve? (more energy, sleep better, less brain fog, lose weight, etc...)* This field is required.

20

What do you think is stopping you from achieving your goals?* This field is required.

21

Are you willing to consume animal products, if necessary, to improve your cellular health?* This field is required.

22

Please list any food allergies.* This field is required.

23

What is your number one fear when it comes to your health?* This field is required.

24

On a scale of 1-10 how committed are you to doing whatever it takes to solve this problem? (1 being not committed, 10 being 100% committed)* This field is required.

25

Why is solving this problem a MUST for you now?* This field is required.

26

Anxiety* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

27

Mood Swings* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

28

Enraged Behavior or Anger* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

29

Excessive shyness, timidity, social phobia (not typical to your personality)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

30

Excessive shyness, timidity, social phobia (not typical to your personality)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

31

Irritability (not typical to your personality)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

32

Low body temperature (below 97.3 F)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

33

Insomnia (can’t get to sleep or return to sleep)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

34

Dizziness* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

35

Sound in ears (ringing or hearing your heart beat)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

36

Psychological symptoms, even thoughts of suicide* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

37

Sensitivity to sound* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

38

Indecisiveness* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

39

Feeling of being overwhelmed or fearful* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

40

Metallic taste in your mouth* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

41

Bad breath* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

42

Bleeding gums* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

43

Sensitive teeth* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

44

Canker sores or other sores in the mouth* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

45

Floaters, shadows or swimmers when you read or look into the sky* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

46

Dyslexia or loss of place while reading, even as a child* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

47

Swelling eyelids* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

48

Peeling on the top layer of skin (hands, feet)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

49

Dry skin* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

50

Heart pain (angina) and you are under 45 years old* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

51

Depression* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

52

Gout (arthritic pain, especially in big toes)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

53

Pain in shoulders or upper back* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

54

Twitching eyelids* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

55

Anemia* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

56

Wrist/ankle drop or weak extensor muscles* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

57

Hair falls out (not normal male pattern baldness)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

58

Sensitivity to light* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

59

Fatigue after exercising (feeling worse)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

60

Bad night vision or seeing halos around lights* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

61

Shortness of breath, with very little effort* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

62

Excessive thirst and/or frequent urination* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

63

Red eyes or tearing* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

64

Blurred vision at times* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

65

Morning stiffness* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

66

Sensitivity to smells (chemicals such as petrochemicals, perfumes, air fresheners)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

67

Chronic fatigue or weakness* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

68

Non-restful sleep* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

69

Receive static shock more often & with more dramatic effect than normal* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

70

Trouble processing new information* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

71

Word reversal or trouble finding words* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

72

Sensitivity to touch* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

73

Short-term memory loss* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

74

Chronic sinus congestion* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

75

Dry non-productive cough* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

76

Muscle twitching* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

77

Excessive sweating, especially at night* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

78

Joint pain - not necessarily true arthritis - can move from joint to joint* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

79

Difficulty losing weight regardless of diet or exercise* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

80

Persistent fungal or viral infection, including athlete’s foot, warts, jock itch, candida* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

81

Frequent illness, prolonged illness or sick days* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

82

Numbness or weakness in arms and legs* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

83

Headaches* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

84

Trouble adding or dividing numbers in your head* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

85

Fluctuating constipation and diarrhea* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

86

Stomach pain for no apparent reason* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

87

Appetite swings* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

88

Frequent muscle aches, cramps, unusual sharp sudden pains* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

89

Rashes or rosacea* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

90

Cold extremities (hands and feet)* This field is required.

0 = Never had symptom

1 = Occasionally have it, mild effect

2 = Occasionally have it, severe effect

3 = Frequently have it, mild effect

4 = Frequently have it, severe effect

91

Calculate up to 60

92

Calculate 61-end