Toxicity Self Test

Rate each of the following symptoms based upon your health profile for the past 30 days. Print it out and return it to us.

POINT SCALE

0= never or almost never have the symptom

1= occasionally have it, effect is not severe

2= occasionally have it, effect is severe

3= frequently have it, effect is not severe

4= frequently have it, effect is severe

DIGESTIVE

___ Nausea or vomiting

___ Diarrhea

___ Constipation

___ Bloated feeling

___ Belching, passing gas

___ Heartburn

___ TOTAL

EARS

___ Itchy ears

___ Earaches, ear infection

___ Drainage from ear

___ Ringing in ears, hearing loss

___ TOTAL

EMOTIONS

___ Mood swings

___ Anxiety, fear, nervousness

___ Anger, irritability

___ Depression

___ TOTAL

ENERGY/ACTIVITY

___ Fatigue, sluggishness

___ Apathy, lethargy

___ Hyperactivity

___ Restlessness

___ TOTAL

EYES

___ Watery, itchy eyes

___ Swollen, reddened or sticky eyelids

___ Dark circles under eyes

___ Blurred/tunnel vision

___ TOTAL

HEAD

___ Headaches

___ Faintness

___ Dizziness

___ Insomnia

___ TOTAL

LUNGS

___ Chest congestion

___ Asthma, bronchitis

___ Shortness of breath

___ Difficulty breathing

___ TOTAL

MIND

___ Poor memory

___ Confusion

___ Poor concentration

___ Poor coordination

___ Difficulty making decisions

___ Stuttering, stammering

___ Slurred speech

___ Learning disabilities

___ TOTAL

MOUTH/THROAT

___ Chronic coughing

___ Gagging, frequent need to clear throat

___ Sore throat, hoarse

___ Swollen or discolored tongue, gums, lips

___ Canker sores

___ TOTAL

NOSE

___ Stuffy nose

___ Sinus problems

___ Hay fever

___ Sneezing attacks

___ Excessive mucus

___ TOTAL

SKIN

___ Acne

___ Hives, rashes, dry skin

___ Hair loss

___ Flushing or hot flashes

___ Excessive sweating

___ TOTAL

HEART

___ Skipped heartbeats

___ Rapid heartbeats

___ Chest pain

___ TOTAL

JOINTS/MUSCLES

___ Pain or aches in joints

___ Arthritis

___ Stiffness, limited movement

___ Pain, aches in muscles

___ Feeling of weakness or tiredness

___ TOTAL

WEIGHT

___ Binge eating/drinking

___ Craving certain foods

___ Excessive weight

___ Compulsive eating

___ Water retention

___ Underweight

___ TOTAL

OTHER

___ Frequent illness

___ Frequent or urgent urination

___ Genital itch, discharge

___ TOTAL

______GRAND TOTAL