Toxicity Questionnaire

The Toxicity Questionnaire is designed to aid the practitioner in assessing a patient's or client's potential need for a purification program.

First Name *

Last Name *

Email *

Phone *

City

State

Section I: Symptoms

Select the following if you occasionally or frequently experience the symptom, based upon your health profile for the past 90 days.

1. DIGESTIVE

a. Nausea and/or vomiting

b. Diarrhea

c. Constipation

d. Bloated feeling

e. Belching and/or passing gas

f. Heartburn

2. EARS

TRUE

FALSE

3. EMOTIONS

a. Mood swings

b. Anxiety, fear, or nervouseness

c. Anger, irritability

d. Depression

e. Sense of despair

f. Uncaring or disinterested

4. ENERGY/ACTIVITY

NRT Basics (Foundational Level)

NRT Intermediate

NRT Advanced Clinical Training

NRT Mastery

5. EYES

Phase 1

Phase 2

Phase 3

Phase 4

Mastery Training

6. HEAD

Just advance technical skill

Freedom and flexibility to go completely remote

Looking to retire from B&M in the next 5 years

7. LUNGS

a. Chest congestion

b. Asthma or bronchitis

c. Shortness of breath

d. Difficulty breathing

8. MIND

a. Poor memory

b. Confusion

c. Poor concentration

d. Poor coordination

e. Difficulty making decisions

f. Stuttering, stammering

g. Slurred speech

h. Learning disabilities

9. MOUTH/THROAT

a. Chronic coughing

b. Gagging or frequent need to clear throat

c. Swollen or discolored tongue, gums, lips

d. Canker sores

10. NOSE

YES

11. SKIN

e. Excessive sweating

12. HEART

a. Skipped heartbeats

b. Rapid heartbeats

c. Chest pain

13. JOINTS/MUSCLES

a. Pain or aches in joints

b. Rheumatoid arthritis

c. Osteoarthritis

d. Stiffness or limited movement

e. Pain or aches in muscles

f. Recurrent back aches

g. Feeling of weakness or tiredness

14. WEIGHT

a. Binge eating or drinking

b. Craving certain foods

c. Excessive weight

d. Compulsive eating

e. Water retention

f. Underweight

15. OTHER

a. Frequent illness

b. Frequent or urgent urination

c. Leaky bladder

d. Genital itch, discharge

Section I Total:

Section II: Risk of Exposure

16. Select the following if there is weekly, monthly, or daily exposure, based upon your environmental profile for the past 120 days.

a. Strong chemicals used in your home (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window clearners, etc.)

b. Pesticides

c. Home treated for insects

d. Exposure to dust, overstuffed furniture, tobacco smoke, mothballs, incense, or varnish in your home or office

e. Nail polish, perfume, hairspray, or other cosmetics

f. Diesel fumes, exhaust fumes, or gasoline fumes

17. Select the following if you have noticed a mild to drastic change

a. Your health since moving into your home or apartment

b. Your health since starting your new job

18. Select the following if it applies

a. No water purification system in your home

b. Indoor pets

c. No air purification system in your home

d. You are a dentist, painter, farm worker, or construction worker

Section II Total:

Grand Total (Section I & Section II)

Add up the number of checkmarks to arrive at a total for each section, and then add the totals for each section to arrive at the grand total. If any individual section total is 7 or more, or the grand total is 15 or more, you could benefit from looking at your toxicity levels further.

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