Toxicity Assessment

TOXICITY ASSESSMENT

The Toxicity Assessment is designed to aid the practitioner in assessing the patient’s need for a Detoxification Program.

SECTION I: SYMPTOMS

Rate each of the following based upon your health profile for the last 90 days.
Use this guide to circle the number of your answer to the following questions:
0 = Never
1 = Rarely
2 = Not severe (Occasionally experience)
3 = Is severe (Often experience)
4 =Very severe (Frequently experience)
HEAD:
A. Headaches 0  1  2  3  4
B. Faintness 0  1  2  3  4
C. Dizziness 0  1  2  3  4
D. Pressure 0  1  2  3  4
TOTAL =                
MIND:
A. Poor memory 0  1  2  3  4
B. Confusion 0  1  2  3  4
C. Poor concentration 0  1  2  3  4
D. Difficulty making decisions 0  1  2  3  4
E. Stuttering, stammering 0  1  2  3  4
F. Slurred speech 0  1  2  3  4
G. Learning disability 0  1  2  3  4
H. Poor coordination 0  1  2  3  4
TOTAL =                
EYES:
A. Watery, itchy eyes 0  1  2  3  4
B. Swollen, reddened 0  1  2  3  4
C. Dark circles under eyes 0  1  2  3  4
D. Blurred tunnel vision 0  1  2  3  4
TOTAL =                 
EARS:
A. Itchy Ears 0  1  2  3  4
B. Ear Aches / Ear Infections 0  1  2  3  4
C. Drainage from Ear 0  1  2  3  4
D. Ringing in Ears / Hearing Loss 0  1  2  3  4
TOTAL =                 
NOSE:
A. Stuffy nose 0  1  2  3  4
B. Sinus problems 0  1  2  3  4
C. Hay fever 0  1  2  3  4
D. Sneezing attacks 0  1  2  3  4
E. Excessive mucous 0  1  2  3  4
TOTAL =
MOUTH / THROAT:
A. Chronic coughing 0  1  2  3  4
B. Gagging, need to clear throat 0  1  2  3  4
C. Swollen or discolored tongue, gums or lips 0  1  2  3  4
TOTAL =                
DIGESTIVE
:
A. Nausea and/or vomiting 0  1  2  3  4
B. Diarrhea 0  1  2  3  4
C. Constipation 0  1  2  3  4
D. Bloated Feeling 0  1  2  3  4
E. Belching and/or passing gas 0  1  2  3  4
F. Heartburn 0  1  2  3  4
TOTAL =                
LUNGS:
A. Chest congestion 0  1  2  3  4
B. Asthma, bronchitis 0  1  2  3  4
C. Shortness of breath 0  1  2  3  4
D. Difficulty breathing 0  1  2  3  4
TOTAL =                
HEART:
A. Skipped heartbeats 0  1  2  3  4
B. Rapid heartbeats 0  1  2  3  4
C. Chest pains 0  1  2  3  4
TOTAL =               
BOWELS / OTHER:
A. Frequent or urgent urination 0  1  2  3  4
B. Leaky bladder 0  1  2  3  4
C. Frequent illness 0  1  2  3  4
TOTAL =                
SKIN:
A. Acne 0  1  2  3  4
B. Hives, rashes or dry skin 0  1  2  3  4
C. Hair loss 0  1  2  3  4
D. Flushing 0  1  2  3  4
E. Excessive sweating 0  1  2  3  4
TOTAL =                 
JOINTS / MUSCLE:
A. Pain or aches in joints 0  1  2  3  4
B. Rheumatoid arthritis 0  1  2  3  4
C. Osteoarthritis 0  1  2  3  4
D. Stiffness / limited movement 0  1  2  3  4
E. Pain / aches in muscle 0  1  2  3  4
F. Frequent back pain 0  1  2  3  4
G. Feeling of weakness or tiredness 0  1  2  3  4
TOTAL =                
WEIGHT:
A. Binge eating / drinking 0  1  2  3  4
B. Craving certain foods 0  1  2  3  4
C. Excessive Weight 0  1  2  3  4
D. Compulsive eating 0  1  2  3  4
E. Water retention 0  1  2  3  4
F. Under weight 0  1  2  3  4
TOTAL =               
EMOTIONS:
A. Mood swings 0  1  2  3  4
B. Anxiety / Fear / Nervousness 0  1  2  3  4
C. Anger / Irritability 0  1  2  3  4
D. Depression 0  1  2  3  4
E. Sense of despair 0  1  2  3  4
F. Lethargy 0  1  2  3  4
TOTAL =                
ENERGY:
A. Fatigue / Sluggishness 0  1  2  3  4
B. Hyperactivity 0  1  2  3  4
C. Restlessness 0  1  2  3  4
D. Insomnia 0  1  2  3  4
E. Startled awake at night 0  1  2  3  4
TOTAL =                
SECTION I TOTALS   ______________

SECTION II: RISK OF EXPOSURE

Rate each of the following based upon your health profile for the last 120 days.
Circle the corresponding number for the following:
0=Never    1=Rarely      2=Monthly     3=Weekly     4=Daily
A. How often are strong chemicals used in your home?
    (Disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners) 0  1  2  3  4
B. How often are pesticides used in your home? 0  1  2  3  4
C. How often do you have your home treated for insects? 0  1  2  3  4
D. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs,
     incense, or varnish in your home or office? 0  1  2  3  4
E. How often are you exposed to nail polish, perfume, hairspray and other cosmetics? 0  1  2  3  4
F. How often are you exposed to diesel fumes, exhaust fumes,or gasoline fumes? 0  1  2  3  4
TOTAL =
Answer Yes or No and circle the corresponding number for the following questions:
A. Do you have a water purification system in your home?
Y=0, N=2
B. Are pesticides used frequently in your home?
Y=2, N=0
C. Do you have an air purification system in your home? Y=0, N=2
D. Are you a dentist, painter, farm worker or construction worker? Y=2, N=0
SECTION II TOTALS   ______________
SECTION I TOTAL =    _______
SECTION II TOTAL =    _______GRAND TOTAL = _______
Add up the numbers to arrive at a total for each section and then add the totals of BOTH sections together to arrive at GRAND TOTAL. If any section is 6 or more, or GRAND TOTAL is 40 or more, you may benefit from a Detox Program. We are here to guide you through your options. Give us a call at 224-521-1212.