No Allergies Please
Root Cause Questionnaire
With respect to Candida, do you experience the following:
*
Rows
Never
Occasional (2x a month)
Frequently (> 2x a week)
Always (almost daily)
Headaches
Muscle Aches
Joint pain
Energy Drops
Fatigue
Sugar/Bread/Carb cravings
Gas/Bloating
Constipation or Diarrhea
Insomnia/Restless sleep
Cold hands, feet or chilliness
PMS/Menstrual irregularities
Fertility issues
Pain/Tightness in Chest
Burning/Tearing of eyes
Irritability
Mood Swings
Depression
Short term memory loss
Brain fog
Short term memory loss
Bruise easily
Sinus congestion/post nasal drip
Dry Mouth/Throat
Frequent/Urgent Urination
Numbness, burning or tingling (fingers, hands or limbs)
Skin rash, irritations (eg. Eczema)
Chemical/Perfume/Tobacco smoke sensitivities
Difficulty losing weight
Loss of libido
Attacks of anxiety/crying
Dizziness/Loss of Balance
Allergies
Total
With respect to mold, do you experience the following:
*
Rows
Never
Occasional (2x a month)
Frequently (> 2x a week)
Always (almost daily)
Home
Work
School
Fatigue
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Brain fog / Memory loss
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Body aches
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Headaches
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Notice musty odours
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Sleep issues / Insomnia
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Anxiety / Depression
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Frequent Nosebleeds
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Unusual skin sensations / Body rashes
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Sinus infections
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Runny, blocked, stuffy nose
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Shortness of Breath or Coughing overnight
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Tightness in chest upon waking
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Feel worse in damp environments
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Chemical sensitivities / Sensitive to smells
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Bloating / Gas / SIBO (small intestine bacterial overgrowth)
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
EMF (electro magnetic field) sensitivities
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Frequent urination
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Water / Plumbing damage
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Visually see mold
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Symptoms change when environment changes
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Experience static shock
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Blurry vision / Changes in vision (not related to glasses)
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Wheezing
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
Heart Palpitations
Better
Worse
Same
Better
Worse
Same
Better
Worse
Same
TOTAL SCORING-- 0 to 25: Low likelihood of mold; 26 to 50: Moderate likelihood of mold; 51 to 75: High likelihood of mold
With respect to Heavy Metals, do you experience the following:
*
Rows
Never
Occasional (2x a month)
Frequently (> 2x a week)
Always (almost daily)
Food Sensitivities
Digestive Issues
Changes in appetite
Seafood twice a week (tuna, salmon)
Metallic taste in mouth
Trouble focusing
Short term memory issues
Can't find words to say / Word reversal
Headaches / Migraines
Easily overwhelmed
Fearful
Anxiety
Unprovoked anger
Irritable
Moody
Unusually timid, shy
Indecisiveness
Depression
Thyroid issues
Sleep issues / Insomnia
Static Shocks
Sensitive skin / Sensitive to touch
Sinus issues
Difficulty losing weight
Low Body Temp (less than 97.5 F / 36.4 C)
Excessive sweating
Cold hands / feet
Weak / Numb extremities
Frequently sick
Autoimmune issues
Allergy shots
Flu shots
Birth control
Contact lenses (1980-1990)
Chronic fungal issues (candida, athletes foot, warts, jock itch)
Rashes / Rosacea
Peeling skin
Dry skin
Muscle cramping, aches, twitching
Joint pain
Chest pain
Gout (arthritic pain especially in big toe)
Stomach Pain
Morning stomach aches
Dizziness / Balance problems
Ringing in the ears
Sensitive to sound
Swollen eyelids
Twitching eyelids
Tooth sensitivity
Bleeding gums
High blood pressure
Low iron
Lose place when reading / dyslexia
Total Input
Do any of these apply to you:
Rows
Yes
No
First Born
Have amalgam / silver fillings
Have amalgam / silver fillings removed
Mother had amalgam / silver fillings when pregnant
Work in dental office
Live near golf course
Live near highway
Live near wires /towers
Live in home built before 1978 with lead paint
Wear perfumes / cologne
Wear regular sunscreens
Use air fresheners
Have fluorescent lighting
Do renovations / construction
Work with metals - molding, soldering, salvage
Work as electrician - wiring, electrical devices, TV glass
Live in mining community
Work with / make ceramics, brass, bronze, crystal
Handle ammunition
Read newspaper prior to 1985
Supplement with coral calcium
Wear cosmetics (esp Kohl)
Have fake leather / vinyl
Dye / Color hair
Total Yes/No
TOTAL SCORING-- 0 to 62: Low likelihood of Heavy Metals; 63 to 124: Moderate likelihood of Heavy Metals; 125 to 186: High likelihood of Heavy Metals
Name
*
First Name
Last Name
Email
*
example@example.com
CandidaMoldHMQuestionnaire Tag
Please verify that you are human
*
See My Results!
Should be Empty: