• Toxicity Questionnaire

  • Questionnaire created by Standard Process.

  • 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  
    •    
    •    
    •    
    •    
    •    
    •    
    • 2. Ears  
    •    
    •    
    •    
    •    
    • 3. Emotions  
    •    
    •    
    •    
    •    
    •    
    •    
    • 4. Energy/ Activity  
    •    
    •    
    •    
    •    
    •    
    • 5. Eyes  
    •    
    •    
    •    
    •    
    • 6. Head  
    •    
    •    
    •    
    •    
    • 7. Lungs  
    •    
    •    
    •    
    •    
    • 8. Mind  
    •    
    •    
    •    
    •    
    •    
    •    
    •    
    •    
    • 9. Mouth/ Throat  
    •    
    •    
    •    
    •    
    • 10. Nose  
    •    
    •    
    •    
    •    
    •    
    • 11. Skin  
    •    
    •    
    •    
    •    
    •    
    • 12. Heart  
    •    
    •    
    •    
    • 13. Joints/ Muscles  
    •    
    •    
    •    
    •    
    •    
    • 14. Weight  
    •    
    •    
    •    
    •    
    •    
    •    
    • 15. Other  
    •    
    •    
    •    
    •    
  • Section 2: Risk of Exposure

    • Environmental  
    • Circle the corresponding number for questions 16a-16g below.

      0 Never
      1 Rarely
      2 Monthly
      3 Weekly
      4 Daily
    •    
    •    
    •    
    •    
    •    
    •    
    •    
    • Changes  
    • Click the corresponding number for questions 17a and 17 b below.

      0 No
      1 Mild Change
      2 Moderate Change
      3 Drastic Change
    •    
    •    
    • Other  
    • Answer yes or no to the following questions.

    • Should be Empty: