Toxicity Questionnaire

Questionnaire created by Standard Process.

First Name Last Name

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

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

	0	1	2	3	4
Rarely or Never						Frequently and Severe

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

0	Never
1	Rarely
2	Monthly
3	Weekly
4	Daily

	1	2	3	4
Never					Daily

	0	1	2	3	4
Never						Daily

	0	1	2	3	4
Never						Daily

	0	1	2	3	4
Never						Daily

	0	1	2	3	4
Never						Daily

	0	1	2	3	4
Never						Daily

	0	1	2	3	4
Never						Daily

Click the corresponding number for questions 17a and 17 b below.

0	No
1	Mild Change
2	Moderate Change
3	Drastic Change

	0	1	2	3
No Change					Drastic Change

	0	1	2	3
No Change					Drastic Change

Answer yes or no to the following questions.

Toxicity Questionnaire

Section 1: Symptoms

Section 2: Risk of Exposure