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Total Toxin Load Questionnaire
Total Toxin Load Questionnaire
Email address
Full Name
Text
Text
PART 1 - OCCURRING SYMPTOMS
Key: Never have the symptom 0 points Rarely and/or very mild 1 point Sometimes and/or effect is mild effect 2 points Fairly often and/or effect is moderate 3 points Very often and/or effect is severe 4 points
GENERAL/ METABOLIC
Feel the Cold
Compulsive eating/drinking alcohol
Water retention
Fatigue/ Sluggishness
Significant weight gain
Cellulite
Significant weight loss
Burning sensation in limbs/hands/feet
Sensitive to strong odours/exhaust/perfumes etc
Rapid heart beat
SKIN
Increased sweating
Skin rashes
Brown spots on hands and face
Boils
Skin tags (small hanging warts)
Hives/rashes/ dry skin
Acne
Psoriasis
Eczema
Fever blisters
Warts
Hair loss (non-hereditary/ Alopecia
COGNITIVE
Hyperactivity
Stammering/ Speech problems
Difficulty in concentration
Difficulty in making decisions
Headache
Poor memory
Poor coordination
Compulsive behaviour
Sleep disturbance
Memory loss
Dizziness /Faintness
Tingling/burning/electrical sensations in the head and body
DIGESTIVE SYSTEM
Loose stools
Heartburn
Constipation
Bloating
Abdominal pain
Intolerance to certain foods
Nausea and vomiting
LIVER/KIDNEY
Fatigue/malaise
Dark coloured urine (not from B vitamins)
Bad breath/coated tongue
Nausea (not pregnant)
Yellow tinge to the skin and eyes /jaundice
Increase in urine frequency and amount
Needing to get up in the night to pass urine
Urinary tract infections/cystitis
Poor appetite in the morning
Kidney stones
Blood in urine or stool
Have a strong reaction to coffee
JOINTS AND MUSCLES
Muscle aches
Aching joints
Tendonitis (sore tendons)
Fibromyalgia (painful muscles)
Gout (high acidity)
Arthritis
Tremours in muscles/hands/wrists
Stiffness/limited movement
MIND/EMOTIONS
Nervousness
Irritability
Mood swings
Frequent crying
Anger or impatient behaviour (e.g. road rage)
Stressed
Anxiety
Confusion
Depression
Panic attacks
Suicidal thoughts
EYES/EARS/NOSE/THROAT
Eyes watery/itchy/red/swollen
Floaters in vision field (dark spots)
Bags or dark circles under eyes
Blurred vision
Mouth ulcers
Frequent colds or flu
Sinusitis/sneezing episodes
Hoarseness in throat
Swollen or discoloured lips/toungue/gums/mouth
Sore throats
Hayfever
Ear Infections
Bronchitis
*
Loss of smell
Cough
PART 2 - ENVIRONMENTAL INFLUENCES
If any of the following statements apply to you, check the corresponding box. If not, just leave blank. N.B. If you are already using known certified organic or chemically free products then do not check the box for that question.
ENVIRONMENTAL INFLUENCES 2A - Do you/have you....
Own a new car (within 12 months)
Recent painting (home painting/artistic)
Used dry-cleaned clothes/linen
Noticed changes in health since moving home
Use industrial chemicals/metal de-greasers
Regularly swim in chlorinated pools /spa (more that 3 times per week
Live in an old home (built prior to 1970)
Moved into a new home/new office built within 1 year
Live on/or near a non-organic farm (within 100 meters)
Use mobile phone/computer/screens daily
Have new carpet/lounge suite/drapes
Been in contact with glues/resins/epoxy (within the last month)
Smoke cigarettes or other smoking
Pesticides/weed killers are used on your property
Work in an industry known to have a toxic environment
Use fumigants/insect repellants
Have fluorescent /energy saving lights
Use moth balls
Use air fresheners
Use non-natural commercial household cleaners
Own known fumigant furniture (in last 2 years)
Live near a golf course (within 100 meters)
Live near an industrial area (within 100 meters)
Live near a landfill (within 100 meters)
Live near power lines (within 100 meters)
Sleep near active electrical items or power points
Have wifi in your home on 24 hours a day
Been exposed to known radiation
Use mildew cleaners/rug/carpet cleaners/spot stain removers
Live in an damp home
Have poor ventilation at home or work
Have an open fireplace
Have gas heating or cooking
Live near or on a busy road
Is your home chemically termite treated
Have a known chemical/heavy metal exposure
ENVIRONMENTAL INFLUENCES 2B - Do you/have you.....
Eat non-organic rice regularly (more than 3 times per week)
Eat non-organic chicken regularly (more than 3 times per week)
Drink coffee each day
Consume gluten containing grains (>3x/w
Consume berries/grapes/stone-fruit/apples (>3x/w)
Eat smoked/cured meat regularly (>3x/w)
Use plastics in your kitchen/home
Eat tuna/shark/swordfish/orange roughy (>3x/w)
Cook with aluminium pots and pans
ConsConsume rice milk/soy milk regularly (>3x/w)
Consume rice milk/soy milk regularly (>3x/w)
Consume cow's milk or dairy products regluarly (>3x/w)
Drink alcohol (more than 7 glasses per week)
Regularly eat canned food (>3x/w)
Regularly touch/handle newsprint/magazines
Use commercial sunscreen regularly (>3x/w)
Use toothpaste with fluoride
Sleep with an electric blanket on
Use a microwave daily
Drink soft drink such as cola and diet sodas (>3x/w)
Eat processed foods regularly (>3x/w)
Use teflon cooking pans
Use commercially fabric softener/spray starch
Drink tap water
Use hairspray
Have mercury fillings
Have had mercury fillings removed in the past 10 years
Use recreational drugs (once per month or more)
Wear commercial makeup/body moisturiser most day
Dye your hair (non-henna)
Use deodorant containing aluminium
Take any medication with suspected toxicity (ask your practitioner)
Use medication for reflux/heartburn (>3x/w)
Use painkillers/steroids/NSAID medication (>3x/w)
Use medications for nerve pain/muscle relaxants (>3x/w)
Regularly use antihistaminic and anticholinergic medication (>3x/w)
Taking mood altering medication (antidepressants/antipsychotics)
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