Toxicity Questionnaire


Name ______________________________    Date ___________

Read the following questions and rate them based on how you have been feeling in the past 30 days.  Fill in the number that applies on the form below:

Key:  0 (or leave blank) = No or never or almost never occurs

1 = occasionally occurs, effect is not severe

2 = occasionally occurs, effect is severe

3 = frequently occurs, effect is not severe

4 = frequently occurs, effect is severe


______ Belching or gas

______ Heartburn or acid reflux

______ Bloating or abdominal discomfort shortly after eating

______ Bad breath

______ Aggravated by certain foods

______ Diarrhea, chronic

______ Undigested food in stool

______ Constipation

______ Nausea or vomiting

______ Fewer than one bowel movement a day

______ Stools are loose and unformed

______ Total


______ Wine makes you sick

______ Easily intoxicated if drinking alcohol

______ Hangovers after drinking alcohol

______ Sensitive to chemicals (perfume, solvents, exhaust)

______ Sensitive to tobacco smoke

______ Hemorrhoids or varicose veins

______ Bothered by aspartame (NutraSweet)

______ Chronic fatigue or Fibromyalgia

______ Feeling wired or jittery if drinking coffee

______ Feet have a strong odor

______ Sweat has a strong odor

______ Total


______ Experience hives, cysts, boils, rashes

______ Cold sores, fever blisters, or herpes lesions

______ Dry flaky skin and/or dandruff

______ Fragile skin, easily chaffed as in shaving

______ Acne

______ Itchy skin / dermatitis

______ Dull colored skin, yellowish, pale or grayish

______ Pale complexion

______ Skin has a sour or unpleasant odor

______ Total


______ Dark circles around the eyes

______ Puffy eyelids

______ Bags under the eyes

______ Bloodshot or reddened eyes

______ Whites of eyes are yellowed

______ Inflamed eyelids

______ Eyes are water and/or itchy

______ Blurred or tunnel vision

______ Total


______ Ridged nails

______ Splitting nails

______ White spots on nails

______ Crumbling nails

______ Total


______ Ear infections

______ Ear drainage or discharge

______ Itchy ears

______ Ringing in the ears

______ Total


______ Stuffy nose

______ Airborne allergies

______ Sinus congestion, “stuffy head”, sinus infections

______ Runny or drippy nose

______ Total


______ Tension headaches at base of skull

______ Splitting type headache

______ Dizziness

______ Faintness

______ Total


______ Coated tongue (yellow, grayish-white or thick film)

______ Swollen tongue

______ Hoarseness

______ Difficulty swallowing

______ Lump in throat

______ Dry mouth, eyes and/or nose

______ Gag easily or need to clear throat often

______ Total


______ Asthma

______ Wheezing or difficulty breathing

______ Shortness of breath

______ Chest congestion

______ Heart races, rapid heartbeat

______ Fast pulse at rest

______ Flush or blush easily or face turns red for no reason

______ Heart skips beats

______ Total


______ Feel spacey, thinking seems slow or fuzzy

______ Bizarre vivid or nightmarish dreams

______ Depressed

______ Worried, apprehensive, anxious

______ Nervous or agitated

______ Mentally sluggish, reduced initiative

______ Difficulty concentrating

______ Mood swings

______ Coordination is poor

______ Poor memory

______ Total


______ Pain or swelling in joints

______ Muscles become easily fatigued

______ Muscle aches and pains

______ Arthritic tendencies

______ Joints are painful upon waking

______ Joint pain after mild exertion

______ Joint pain experienced after eating certain foods

______ Abdomen tends to hang out

______ Surface of abdomen is uneven and distended

______ Use of over-the-counter medications

______ Total


______ Pulse speeds after eating

______ Night sweats

______MSG sensitivity

______ Mood swings associated with periods (PMS)

______ Breast tenderness associated with cycle

______ Total


______ Weakness

______ Easily fatigued, sleepy during the day

______ Fatigue is persistent and extreme

______ Apathetic and lethargic

______ Tired, even after a good nights rest

______ Total


______ Crave bread or pasta

______ Crave certain foods

______ Retaining water

______ Excessive weight

______ Total


______ Urine has a strong odor

______ Pain in mid back region

______ Urine is frothy

______ Urinate infrequently

______ Total


______ Frequent infections (bladder, skin, ear, chest, sinus)

______ Frequent colds or flu

______ Herpes outbreaks

______ Total


______ Food allergies

______ Feel worse in moldy or musty places

______ Total

Please add the numbers from each section and write the total in the spaces provided, then add all the totals for each section together and put that total in the space below.

GRAND TOTAL ________

If any individual section is 6 or more and your grand total is more than 40 you may benefit from a purification program:)

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