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Toxicity and Inflammation Questionnaire

General Signs and Symptoms

This questionnaire identifies signs and symptoms that can help your doctor address the underlying cause of your GI-related illness (toxins, inflammation, etc.). This questionnaire is to be completed before and after the suggested protocol your doctor recommends for you. This will help him or her track your progress over time.

Note: All fields are required.

   
 
    First Name  
 
    Last Name  
 
    Your Email  
 
 
  ANSWER KEY: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
 
Select the correct answer for you.
 
 
 
0
1
2
3
4
    HEAD
    1. Headaches
    2. Dizziness
    3. Insomnia
    4. Faintness
 
 
0
1
2
3
4
    EARS
    5. Itchy ears
    6. Ringing in ears/loss of hearing
    7. Ear aches/ear infections
    8. Drainage from ear
   
   
 
0
1
2
3
4
    EYES
    9. Bags or dark circles under eyes
    10. Watery or itchy eyes
    11. Swollen, reddened,or sticky eyelids
    12. Blurred or tunnel vision
    (excluding near or far sightedness)
 
 
0
1
2
3
4
    NOSE
    13. Stuffy nose
    14. Sinus congestion, sinus infection
    15. Constant sneezing
    16. Hay fever/allergies
    17. Excess mucus formation
   
   
 
0
1
2
3
4
    MOUTH/THROAT
    18. Chronic coughing
    19. Sore throat, hoarseness, loss of voice
    20. Gagging, frequent need to clear throat
    21. Swollen tongue, gums or lips
    22. Swollen lymph nodes
    23. Canker sores, mouth ulcers
 
 
0
1
2
3
4
    HEART
    24. Chest pain
    25. Irregular or skipped heartbeat
    26. Rapid or pounding heartbeat
    
    
    
   
   
 
0
1
2
3
4
    LUNGS
    27. Asthma, bronchitis
    28. Chest congestion
    29. Shortness of breath
    30. Difficulty breathing
    
    
    
 
 
0
1
2
3
4
    SKIN
    31. Acne or brown "age/liver spots"
    32. Hives, rashes, cysts, boils
    33. Eczema or psoriasis
    34. Itchy skin/dermatitis
    35. Hair loss, hair thinning
    36. Body odor
    37. Excessive sweating
   
   
 
0
1
2
3
4
   JOINTS/MUSCLES
    38. Pain or aches in joints or lower back
    39. Stiffness or limitation of movement
    40. Arthritis
    41. Pain or aches in muscles
    
    
    
 
 
0
1
2
3
4
    MENTAL/EMOTIONAL
    42. Poor memory
    43. Difficulty concentration
    44. Mood swings
    45. Depression
    46. Anxiety, fear or nervousness
    47. Anger, irritability, or aggressiveness
    48. Insomnia
   
   
 
0
1
2
3
4
    ENERGY LEVEL
    49. Fatigue/low energy
    50. Restlessness
    51. Hyperactivity
    52. Feeling of weakness
 
 
0
1
2
3
4
    WEIGHT
    53. Underweight
    54. Overweight
    55. Difficulty losing weight
    56. Crave certain foods
   
   
 
0
1
2
3
4
    DIGESTIVE TRACT
    57. Nausea, vomiting
    58. Diarrhea
    59. Constipation
    60. Bloated feeling
    61. Belching, passing gas
    62. Heartburn
    63. Intestinal/stomach pain
 
 
0
1
2
3
4
    OTHER
    64. PMS
    65. Frequent colds, flus
    66. Chemical or environmental sensitivities
    67. Food allergies/sensitivities