Toxicity Symptom Questionnaire

Digestive- record your symptoms for the past 3 months
Nausea or Vomiting
Diarrhea
Constipation
Bloating
Belching or gas
Heartburn
Eyes- record your symptoms for the past 3 months
Watery or itchy
Swollen, red or irritated eyelids
Dark circles under eyes
Ears- record your symptoms for the past 3 months
Itchy ears
Earaches or fluid in ears
Ringing in ears
Head- record your symptoms for the past 3 months
Headaches
Faintness
Dizziness
Emotions- record your symptoms for the past 3 months
Mood swings
Anxiety, fear or nervousness
Depression or sadness
Lungs- record your symptoms for the past 3 months
Chest congestion
Shortness of breath
Asthma or bronchitis
Energy/Activity- record your symptoms for the past 3 months
Fatigue or sluggishness
Restlessness
Insomnia
Mind- record your symptoms for the past 3 months
Poor memory
Brain fog
Difficulty making decisions
Poor concentration
Mouth/Throat- record your symptoms for the past 3 months
Chronic coughing
Swollen or discolored tongue, gums, or lips
Gagging or need to clear throat
Nose- record your symptoms for the past 3 months
Stuffy nose
Sinus problems
Sneezing attacks
Excessive mucus
Skin- record your symptoms for the past 3 months
Acne
Hives, rashes, or dry skin
Hair loss
Heart- record your symptoms for the past 3 months
Skipping or rapid heartbeats
Chest pains
High cholesterol/triglycerides/blood sugar
Joints/Muscles- record your symptoms for the past 3 months
Pain or aches in joints or muscles
Stiffness or limited movement
Feeling weak or tired in limbs
Weight- record your symptoms for the past 3 months
Binge eating or craving certain foods
Swelling or water retention
Gained 5lbs in past 3 months
Other- record your symptoms for the past 3 months
Frequent Illness
Frequent or urgent urination
Leaky bladder or UTI's
Toxin Exposure
Use scented cleaners/candles/nail polish/cosmetics
Drink public water
Eat packaged food
Use pesticides/herbicides in or around home
Live near farmland
Take Medication OTC or Prescribed
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