Medical Symptoms and Toxicity Questionnaire

1
Name* This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Date:* This field is required.
Date
Month
Day
Year
4
Medical Symptoms and Toxicity Questionnaire

This questionnaire is designed to help identify symptoms that may reveal the underlying causes of your health concerns while tracking your progress over time. Please provide honest answers based on your current symptoms.

Before starting your Path to Peak Wellness Program, rate each symptom according to your health profile over the past 30 days. This questionnaire will be completed again during the program to record symptoms from the previous three weeks.

After submission, you will receive an email summarizing your responses and score. Your provider will receive an email with your name, date, and overall score, but no other details will be included.

Thank you for taking this important step toward improving your health and well-being!
5
Point Scale

0 = Never, or almost never have the symptom

1 = Occasionally have it, the effect is NOT severe

2 = Occasionally have it, the effect is severe

3 = Frequently have it, the effect is NOT severe

4 = Frequently have it, the effect is severe
6
Nausea or vomiting
0
1
2
3
4
None
Frequent/severe
7
Diarrhea
0
1
2
3
4
None
Frequent/severe
8
Constipation
0
1
2
3
4
None
Frequent/severe
9
Bloated feeling
0
1
2
3
4
None
Frequent/severe
10
Belching or passing gas
0
1
2
3
4
None
Frequent/severe
11
Heartburn
0
1
2
3
4
None
Frequent/severe
12
Intestinal/ Stomach pain
0
1
2
3
4
None
Frequent/severe
13
Digestive Tract Total
14
Chronic Coughing
0
1
2
3
4
None
Frequent/severe
15
Canker sores
0
1
2
3
4
None
Frequent/severe
16
Sore throat, loss of voice, hoarseness
0
1
2
3
4
None
Frequent/severe
17
Gagging, frequent need to clear throat
0
1
2
3
4
None
Frequent/severe
18
Swollen/discolored tongue, gum, lips
0
1
2
3
4
None
Frequent/severe
19
Mouth/Throat Total
20
Headaches
0
1
2
3
4
None
Frequent/severe
21
Faintness
0
1
2
3
4
None
Frequent/severe
22
Dizziness
0
1
2
3
4
None
Frequent/severe
23
Insomnia
0
1
2
3
4
None
Frequent/severe
24
Head Total
25
Itchy ears
0
1
2
3
4
None
Frequent/severe
26
Earaches, ear infections
0
1
2
3
4
None
Frequent/severe
27
Drainage from ear
0
1
2
3
4
None
Frequent/severe
28
Ringing in ears, hearing loss
0
1
2
3
4
None
Frequent/severe
29
Ears Total
30
Irregular or skipped heartbeat
0
1
2
3
4
None
Frequent/severe
31
Rapid or pounding heartbeat
0
1
2
3
4
None
Frequent/severe
32
Chest pain
0
1
2
3
4
None
Frequent/severe
33
Heart Total
34
Stuffy nose
0
1
2
3
4
None
Frequent/severe
35
Sinus problems
0
1
2
3
4
None
Frequent/severe
36
Hay fever
0
1
2
3
4
None
Frequent/severe
37
Sneezing attacks
0
1
2
3
4
None
Frequent/severe
38
Excessive mucus formation
0
1
2
3
4
None
Frequent/severe
39
Nose Total
40
Mood swings
0
1
2
3
4
None
Frequent/severe
41
Anxiety, fear or nervousness
0
1
2
3
4
None
Frequent/severe
42
Anger, irritability, or aggressiveness
0
1
2
3
4
None
Frequent/severe
43
Depression
0
1
2
3
4
None
Frequent/severe
44
Emotions Total
45
Pain or aches in joints
0
1
2
3
4
None
Frequent/severe
46
Arthritis
0
1
2
3
4
None
Frequent/severe
47
Pain or aches in muscles
0
1
2
3
4
None
Frequent/severe
48
Feeling of weakness or tiredness
0
1
2
3
4
None
Frequent/severe
49
Stiffness or limitation of movement
0
1
2
3
4
None
Frequent/severe
50
Joint/Muscles Total
51
Acne
0
1
2
3
4
None
Frequent/severe
52
Hair loss
0
1
2
3
4
None
Frequent/severe
53
Hives, rashes, or dry skin
0
1
2
3
4
None
Frequent/severe
54
Flushing or hot flushes
0
1
2
3
4
None
Frequent/severe
55
Excessive sweating
0
1
2
3
4
None
Frequent/severe
56
Skin Total
57
Fatigue, sluggishness
0
1
2
3
4
None
Frequent/severe
58
Apathy, lethargy
0
1
2
3
4
None
Frequent/severe
59
Hyperactivity
0
1
2
3
4
None
Frequent/severe
60
Restlessness
0
1
2
3
4
None
Frequent/severe
61
Energy/Activity Total
62
Chest congestion
0
1
2
3
4
None
Frequent/severe
63
Asthma, bronchitis
0
1
2
3
4
None
Frequent/severe
64
Shortness of breath
0
1
2
3
4
None
Frequent/severe
65
Difficult breathing
0
1
2
3
4
None
Frequent/severe
66
Lungs Total
67
Binge eating/drinking
0
1
2
3
4
None
Frequent/severe
68
Craving certain foods
0
1
2
3
4
None
Frequent/severe
69
Excessive weight
0
1
2
3
4
None
Frequent/severe
70
Compulsive eating
0
1
2
3
4
None
Frequent/severe
71
Water retention
0
1
2
3
4
None
Frequent/severe
72
Underweight
0
1
2
3
4
None
Frequent/severe
73
Weight Total
74
Watery or itchy eyes
0
1
2
3
4
None
Frequent/severe
75
Swollen, reddened or sticky eyelids
0
1
2
3
4
None
Frequent/severe
76
Bags or dark circles under eyes
0
1
2
3
4
None
Frequent/severe
77
Blurred or tunnel vision (does not include near-or far-sightedness)
0
1
2
3
4
None
Frequent/severe
78
Eyes Total
79
Poor memory
0
1
2
3
4
None
Frequent/severe
80
Confusion, poor comprehension
0
1
2
3
4
None
Frequent/severe
81
Poor concentration
0
1
2
3
4
None
Frequent/severe
82
Poor physical coordination
0
1
2
3
4
None
Frequent/severe
83
Difficulty in making decisions
0
1
2
3
4
None
Frequent/severe
84
Stuttering or stammering
0
1
2
3
4
None
Frequent/severe
85
Slurred speech
0
1
2
3
4
None
Frequent/severe
86
Learning disabilities
0
1
2
3
4
None
Frequent/severe
87
Mind Total
88
Frequent illness
0
1
2
3
4
Never
Frequent/severe
89
Frequent or urgent urination
0
1
2
3
4
Never
Frequent/severe
90
Genital itch or discharge
0
1
2
3
4
Never
Frequent/severe
91
Other Total
92
GRAND TOTAL
93
Your Results:

Less than 10 = Optimal

10 - 50 = Mild Toxicity

51 - 100 = Moderate Toxicity

Over 100 = Severe Toxicity
Should be Empty: