Toxicity Questionnaire

Toxicity Questionnaire
Questionnaire created by Standard Process.
Name

First Name Last Name
Email
example@example.com
Who is your inBalance Provider?
Section 1: Symptoms

Rate each of the following symptoms based upon your health profile for the past 90 days.

Click the corresponding number for each symptom.

0	Rarely or Never Experience the Symptom
1	Occasionally Experience the Symptom, Effect is Not Severe
2	Occasionally Experience the Symptom, Effect is Severe
3	Frequently Experience the Symptom, Effect is Not Severe
4	Frequently Experience the Symptom, Effect is Severe

1. Digestive

1a. Nausea and/or vomiting

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

1b. Diarrhea

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

1c. Constipation

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

1d. Bloated feeling

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

1e. Belching and/or passing gas

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

1f. Heartburn

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

2. Ears

2a. Itchy ears

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

2b. Earaches or ear infections

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

2c. Drainage from ear

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

2d. Ringing in ears or hearing loss

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

3. Emotions

3a. Mood swings

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

3b. Anxiety, fear, or nervousness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

3c. Anger, irritability

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

3d. Depression

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

3e. Sense of despair

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

3f. Uncaring or disinterested

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

4. Energy/ Activity

4a. Fatigue or sluggishness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

4b. Hyperactivity

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

4c. Restlessness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

4d. Insomnia

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

4e. Startled awake at night

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

5. Eyes

5a. Watery or itchy eyes

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

5b. Swollen, reddened, or sticky eyelids

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

5c. Dark circles under eyes

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

5d. Blurred or tunnel vision

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

6. Head

6a. Headaches

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

6b. Faintness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

6c. Dizziness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

6d. Pressure

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

7. Lungs

7a. Chest congestion

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

7b. Asthma or bronchitis

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

7c. Shortness of breath

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

7d. Difficulty breathing

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8. Mind

8a. Poor memory

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8b. Confusion

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8c. Poor concentration

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8d. Poor coordination

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8e. Difficulty making decisions

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8f. Stuttering, stammering

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8g. Slurred speech

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

8h. Learning disabilities

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

9. Mouth/ Throat

9a. Chronic coughing

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

9b. Gagging or frequent need to clear throat

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

9c. Swollen or discolored tongue, gums, lips

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

9d. Canker sores

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

10. Nose

10a. Stuffy nose

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

10b. Sinus problems

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

10c. Hay fever

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

10d. Sneezing attacks

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

10e. Excessive mucous

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

11. Skin

11a. Acne

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

11b. Hives, rashes, or dry skin

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

11c. Hair loss

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

11d. Flushing

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

11e. Excessive sweating

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

12. Heart

12a. Skipped heartbeats

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

12b. Rapid heartbeats

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

12c. Chest pain

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

13. Joints/ Muscles

13a. Pain or aches in joints

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

13b. Stiffness or limited movement

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

13c. Pain or aches in muscles

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

13d. Recurrent back aches

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

13e. Feeling of weakness or tiredness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

14. Weight

14a. Binge eating or drinking

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

14b. Craving certain foods

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

14c. Excessive weight

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

14d. Compulsive eating

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

14e. Water retention

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

14f. Underweight

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

15. Other

15a. Frequent illness

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

15b. Frequent or urgent urination

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

15c. Leaky bladder

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe

15d. Genital itch, discharge

	0	1	2	3	4

0 is Rarely or Never, 4 is Frequently and Severe