Registration Form
Please fill in the form below.
Full Name
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Prefix
First Name
Last Name
Phone Number
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Area Code
Phone Number
E-mail
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1. Digestive
a. Nausea and/or Vomiting
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Diarrhea
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Constipation
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Bloating feeling
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Belching and /or passing gas
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
f Heart burn
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
Digestive Total
2. EARS
a. Itchy ears
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Earaches or ear infections
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Drainage of ears
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Ringing in ears or hearing loss
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
EAR QUESTION TOTAL
3. EMOTIONS
a. Mood swings
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Anxiety, fear, or nervousness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Anger, irritability
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Depression
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Sense of despair
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
f. Uncaring or disinterested
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
EMOTIONS TOTAL
4. ENERGY / ACTIVITY
a. Fatigue or sluggishness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Hyperactivity
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Restlessness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Insomnia
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Startled awake at night
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
ENERGY/ ACTIVITY TOTAL
5. EYES
a. Watery or itchy eyes
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Swollen, red and or sticky eyelids
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Dark circles under eyes
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Blurred or tunnel vision
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
EYES TOTAL
6. HEAD
a. Headaches
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Faintness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Dizziness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Pressure
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
HEAD TOTAL
7. LUNGS
a. Chest congestion
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Asthma or bronchitis
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Shortness of breath
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Difficulty breathing
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
LUNG TOTAL
8. MIND
a. Poor memory
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Confusion
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Poor concentration
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Poor coordination
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Difficulty making decisions
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
f. Stuttering, stammering
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
g. Slurred speech
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
h. Learning disabilities
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
MIND TOTAL
9. MOUTH/THROAT
a. Chronic coughing
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Gagging or frequent need to clear throat
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Swollen or discolored tongue, gums, lips
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Canker sores
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
MOUTH/THROAT
10. NOSE
a. Stuffy nose
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Sinus problems
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Hayfever
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Sneezing attacks
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Excessive mucus
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
NOSE TOTAL
11. SKIN
a. Acne
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Hives, rashes, or dry skin
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Hair loss
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Flushing
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Excessive sweating
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
SKIN TOTAL
12. HEART
a. Skipped heartbeats
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Rapid heartbeats
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Chest pains
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
HEART TOTAL
13. JOINTS/
a. Pain or aches in joints
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
b. Rheumatoid arthritis
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
c. Osteoarthritis
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
d. Stiffness or limited movement
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
e. Pain or aches and muscles
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
F. Recurrent backaches
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
G. Feeling of weakness or tiredness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
Joints/muscles total
14. WEIGHT
A. Binge eating or drinking
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
B. Craving certain foods
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
C. Excessive weight
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
D. Compulsive eating
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
E. Water retention
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
F. Underweight
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
WEIGHT TOTAL
15. OTHER:
A. Frequent illness
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
B. Frequent or urgent urination
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
C. Leaky bladder
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
D. Genital itch or discharge
Rarely or never experience this symptom
Occasionally experience the symptoms, effect is not severe
Occasionally experience this symptom, affect is severe
Frequently experience this symptom, effect is not severe
Frequently experience the symptom, effect is severe
OTHER TOTAL
SECTION 1 TOTAL
SECTION 2: RISK OF EXPOSURE
Rate each of the following situations based upon your environmental profile for the past 120 days.
16. Circle the corresponding number of the questions 16 A-16 F below
A. How often are strong chemicals used in your home? Disinfectants bleach, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.
Never
Rarely
Monthly
Weekly
Daily
B. How often are pesticides used in your home
Never
Rarely
Monthly
Weekly
Daily
C. How often do you have your home treated for insects?
Never
Rarely
Monthly
Weekly
Daily
D. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office?
Never
Rarely
Monthly
Weekly
Daily
E. How often are you exposed to nail polish, perfume, hairspray, or other cosmetics?
Never
Rarely
Monthly
Weekly
Daily
F. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?
Never
Rarely
Monthly
Weekly
Daily
Number 16 total
17. Click on the corresponding number for question 17 A-17 B below
A. Have you noticed any negative changes in your health since you moved into your home or apartment?
No
Mild change
Moderate change
Drastic change
B. Have you noticed any change in your health since you started your new job?
No
Mild change
Moderate change
Drastic change
17 total
18. Answer yes or no by clicking on the corresponding answer for questions 18 A-18 D below
A. Do you have a water purification system in your home?
yes
no
B. Do you have any indoor pets?
yes
no
C. Do you have an air purification system in your home?
yes
no
D. Are you a dentist, painter, farmworker, or construction worker?
yes
no
18 total
Section 2 total
Grand Total (Sections I & II) if any individual section total is six or more, or the grand total is 40 or more, you may benefit from a purification program.
Completed, please click on submit form
Adapted with permission from the author of clinical per purification: A Complete Treatment and Reference manual, Dr. Gina L Nick
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