Medical screening questionnaire
This Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past 30 days. If you are taking after the first time, record your symptoms for the last 48 hours ONLY.

POINT SCALE
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
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Email *
Digestion - Gut health *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Nausea or Vomiting
Diarrhoea
Constipation
Bloating
Frequent belching after meals
Passing excessive gas
Stomach pain or intestinal pain
Indigestion or heatburn
Ears *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Itchy Ears
Earaches / Recurrent ear infections
Tinnitus / Ringing in the ears
Poor hearing
Mouth / Throat *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Chronic coughing
Gagging / Frequent need to clear the throat
Sore throat / Hoarseness / Loss of voice
Swollen or discoloured tongue, gum or lips
Tooth decay or gum disease
Sore cracked mouth / lips
Frequent ulcers
Nose *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Stuffy nose
Sinus problems
Hayfever
Sneezing attacks
Excessive mucous formation
Eyes *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Watery / itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under the eyes
Blurred or tunnelled vision (does not include short of long sightedness)
Lungs *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Chest congestion
Asthma / Bronchitis
Shortness of breath
Difficultly breathing
Heart *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Irregular heartbeat
Rapid pounding heart
Chest pain
Head *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Frequent headaches / Migraine
Faintness
Dizziness
Insomnia
Urinary tract and reproductive system *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Frequent urinary tract infection
Yeast or fungal infections
Frequent urination with excessive thirst
Joints and Muscles *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Aches and pains in joints
Arthritis
Stiffness or limitation of movement
Pain of aches in muscles
Feeling of weakness or tiredness
Skin *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Acne or rosacea
Hives
Hair loss
Excessive flushing or hot flushes
Excessive sweating
Weight *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Binge eating
Craving certain foods
Excessive weight
Compulsive or emotional eating
Water retention
Underweight
Emotions *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Mood swings
Anxiety, fear or nervousness
Anger, irritability or aggressiveness
Depression
Energy / Activity *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Fatigue / Sluggishness
Apathy / Lethargy
Hyperactivity
Restlessness
Mind *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Poor memory
Confusion of poor comprehension
Poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering or stammering
Slurred speech
Learning difficulties
General wellbeing *
Score = 0
Score = 1
Score = 2
Score = 3
Score =4
Poor immunity / frequent illness
Problems with menstrual cycle