Ingested toxin score

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Email *

I filter my tap water with a reverse osmosis filter or high-efficacy charcoal filter (Berkey) and rarely ever drink unfiltered water *

1 point

I have check my water quality against the Environmental Working Group database and understand whether specific contaminants are above recommended levels *

1 point

I drink at least half an ounce of water per pound of body weight per day *

1 point

When I leave the house, I bring filtered water in a non-plastic bottle *

1 point

I avoid drinking water out of single-use plastic bottles *

1 point

I avoid foods that have natural flavors or artificial flavors *

1 point

I do not eat foods with any artificial dyes in them *

1 point

I rarely store my food in plastic containers or buy food in plastic containers, and instead opt for metal or glass storage *

1 point

I do not drink more than one alcoholic beverage per day *

1 point

I do not drink more than 7 alcoholic beverages per week *

1 point

I do not smoke cigarettes or other tobacco products *

1 point

I do not use chewing tobacco or similar forms of chewable nicotine *

1 point

I do not smoke cigars *

1 point

I do not vape *

1 point

I avoid OTC medications, like acetaminophen (Tylenol), ibuprofen, diphenhydramine, ant-acids and use them less than 5 times per year *

1 point

I have not taken oral antibiotics in the past 2 years *

1 point

I do not eat high-mercury fish (tuna,, lobster, bass, swordfish, halibut, marlin) more than once per week *

1 point

I want a call back to discuss this questionnaire *

1 point

Phone number

1 point

Best time to call

1 point

8am - 10am EST

10 am - 2 pm EST

2pm - 6pm EST

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

Forms

reCAPTCHA

Privacy Terms

This form was created inside of South Carolina Chiropractic Neurology.