Worksheet

Neuro-Toxin Assessment

🚨 Is Neurotoxicity Holding You Back? Take the First Step to Reclaim Your Health! 🚨

Brain fog, chronic fatigue, headaches, anxiety, and stubborn weight gain—these could all be signs of hidden neurotoxicity wreaking havoc on your body. Toxins from mold, heavy metals, pesticides, and everyday chemicals can silently disrupt your brain and nervous system, leaving you feeling drained and unwell.

🔎 Our Neurotoxicity Assessment helps uncover the root cause of your symptoms so we can take control of your health. Don’t let hidden toxins dictate how you feel—get the answers you need today!

📋 Take the FREE Assessment Now!

All your information is kept confidential.

We will be reaching out to you soon to review your results...

1. ➜

Information

Names:

Address:

Phone#:

Date of Birth:

2. ➜

Information

Email Address:

Gender: Male or Female

Height & Weight:

5. ➜

Occupation

Name of Employer: Hours per Week Worked:

6. ➜

How did you hear about our Wellness & Nutrition Program?

7. ➜

What is your major Complaint? Pease list when each symptom began and be as descriptive as possible:

8. ➜

What are your current Medications:

9. ➜

What is your current vitamin and/or supplements:

10. ➜

Please list your current and past health conditions (i.e. Diabetes Mellitus, etc):

11. ➜

Is there anything else in your medical history that you consider to be relevant? (Even from Childhood):

12. ➜

What is your employment history? Please provide brief summary including dates if possible:

13. ➜

Please list your past or present Hobbies that could be sources of toxicity or chemicals:

14. ➜

How often are you involved in these Hobbies currently:

15. ➜

Please list past or present allergies, including allergies to medications:

16. ➜

Please list all past surgeries and the condition each surgery was for, including dates:

17. ➜

Please explain your housing history (type of homes, where and when):

18. ➜

Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank.

19. ➜

Mercury

20. ➜

Do you have amalgam (silver) fillings in your teeth?

Yes

21. ➜

If so, How Many?

22. ➜

Have you ever had an amalgam removed?

Yes

23. ➜

If yes, How many & Date removed?

24. ➜

If you had amalgams removed, was it done by a biological dentist using a safe protocol?

Yes

25. ➜

Did your mother have amalgam when pregnant with you?

Yes

26. ➜

Have you ever worked in a dental office?

Yes

27. ➜

If so, How long?

28. ➜

Have you had any dental crowns?

Yes

29. ➜

If so, how many?

30. ➜

Have you had any bridges?

Yes

31. ➜

Have you had any root canals?

Yes

32. ➜

Have you had any tooth extractions?

Yes

33. ➜

Do you have any dental implants, retainers or other metal in your mouth?

Yes

34. ➜

Did you wear contact lenses during the 1980's or early 1990's?

Yes

35. ➜

Did you take oral contraceptives during the 1980's or early 1990's?

Yes

36. ➜

Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?

Yes

37. ➜

Have you noticed any adverse reactions to these shots?

Yes

38. ➜

Do you have any tattoos with red ink?

Yes

39. ➜

Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

Yes

40. ➜

Lead

41. ➜

Does your occupation involve soldering or metal salvage?

Yes

42. ➜

Have you done any old home repaid or sandblasting?

Yes

43. ➜

If so , when?

44. ➜

Do you do a lot of painting?

Yes

45. ➜

Was your home built before 1978?

Yes

46. ➜

Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)

Yes

47. ➜

Are you around a lot of fake leather, or vinyl?

Yes

48. ➜

Do you get stomach aches in the morning?

Yes

49. ➜

General Toxicity

50. ➜

Have you ever lived near, or or by a golf course, freeway or tension wires?

Yes

51. ➜

If yes, please explain:

52. ➜

Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)

Yes

53. ➜

Do you have your house sprayed with pesticides for pest control?

Yes

54. ➜

Do you spray herbicide (weed killers) in or around your home?

Yes

55. ➜

Do you use conventional insect repellants on your self or family?

Yes

56. ➜

Do you use conventional sunscreen?

Yes

57. ➜

Do you use conventional perfume or cologne every day?

Yes

58. ➜

Do you get your hair colored?

Yes

59. ➜

Do you use aerosol hairspray?

Yes

60. ➜

If so, how often?

61. ➜

Do you use air freshener in your house, work or car?

Yes

62. ➜

Do you drink filtered water?

Yes

63. ➜

Do you drink filtered water?

Yes

64. ➜

If so, what type of filter do you have?

Yes

65. ➜

Do you drink bottle water?

Yes

66. ➜

Do you have a water filtration system for your entire house or shower filtration?

Yes

67. ➜

Does your spouse or other family members work around chemicals?

Yes

68. ➜

Can you think of any other toxic exposures you may have had?

Yes

69. ➜

Molds

70. ➜

How old is the hour you are living in? How long have you lived there? Have you noticed symptoms since moving in? If so, what?

71. ➜

Do you see mold growing in your home, work or school?

Yes

72. ➜

Have you ever had water damage in your home, work or school?

Yes

73. ➜

Does you home, workplace or school have a damp or mildew smell?

Yes

74. ➜

Does spending time in your basement cause or worsen your symptoms?

Yes

75. ➜

Does your basement ever get wet?

Yes

76. ➜

Do you have a crawl space?

Yes

77. ➜

Does you basement or crawl space have a sump pump?

Yes

78. ➜

Does spending time ion a different location for at least a few days cause a noticeable decrease in your symptoms?

Yes

79. ➜

Does your car have a mildew smell?

Yes

80. ➜

Does anyone in your home have asthma like symptoms?

Yes

81. ➜

Does anyone in your family have chronic sinus infections or irritations?

Yes

82. ➜

Lyme Disease

83. ➜

Have you ever been diagnosed with Lyme Disease?

84. ➜

Have you had dry sockets or infected tooth extractions?

Yes

85. ➜

Do you have small joint pain?

Yes

86. ➜

Have you ever been bitten by a tick or recluse spider?

Yes

87. ➜

Have you ever seen a bulls-eyes rash appear on any part of your body?

Yes

88. ➜

Did the bulls-eyes rash appear shortly after following a tick, spider bits or time spent outdoors?

Yes

89. ➜

Was your mother ever diagnosed with Lyme Disease?

Yes

90. ➜

Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition?

Yes

91. ➜

Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

Yes

92. ➜

Health History

93. ➜

Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

Yes

94. ➜

Does anyone in your family experience similar symptoms to yours?

Yes

95. ➜

What is your birth order (i.e. First born, second, third, etc.)?

Yes

96. ➜

Do you have any history of kidney dysfunction?

Yes

97. ➜

Do you or any immediate family member have a history with cancer?

Yes

98. ➜

Do you have any history of heart disease, myocardial infarction (heart attack), etc.?

Yes

99. ➜

Are you currently having any thoughts of suicide?

Yes

100. ➜

Have you every been diagnosed with bipolar disorder, schizophrenia or depression?

Yes

101. ➜

Do you have a history of strokes?

Yes

102. ➜

Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?

Yes

103. ➜

Have you ever been in an auto accident, fallen or received a major physical injury?

Yes

104. ➜

Are you in menopause?

Yes

105. ➜

Microbiome Health

106. ➜

Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, brussels sprouts or other vegetables?

Yes

107. ➜

Do you often have gas that has a sulfur or foul smell?

Yes

108. ➜

Are you sensitive to supplements?

Yes

109. ➜

Have you ever been vegan or vegetarian for any length of time?

Yes

110. ➜

Can you tolerate Meat?

Yes

111. ➜

Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?

Yes

112. ➜

Have you taken birth control or hormone replacement therapy for any length of time?

Yes

113. ➜

If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

Yes

114. ➜

Have been on antibiotics for any extended period of time or often as a child or adult?

Yes

115. ➜

Were you caesarian delivered?

Yes

116. ➜

Were you breast fed?

Yes

117. ➜

Does your get temporarily feel better after a round of antibiotics?

Yes

118. ➜

How many times a day are you having a bowel movement?

119. ➜

Rate Symptoms

Rate each of the following symptom to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank.

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect

1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect

120. ➜

Anxiety

121. ➜

Mood swings

122. ➜

Enraged behavior or anger for no reason

123. ➜

Excessive shyness, timidity, social phobia (not typical to your personality)

124. ➜

Irritability (not typical to your personality)

125. ➜

Low body temperature (below 97.5)

126. ➜

Insomnia (can't get to sleep or return to sleep)

127. ➜

Dizziness

128. ➜

Sound in ears (ringing or hearing your heart beat)

129. ➜

Psychological symptoms, even thoughts of suicide

130. ➜

Sensitivity to sound

131. ➜

Indecisiveness feeling of being overwhelmed or fearful

132. ➜

Metallic taste in your mouth

133. ➜

Bad breath, Bleeding gums, Sensitive teeth

134. ➜

Canker sores or other sores in the mouth

135. ➜

Floaters, shadows or swimmers when you read or look into the sky

136. ➜

Dyslexia or loss of place while reading, even as a child

137. ➜

Swelling eyelids

138. ➜

Peeling on top layer of skin (hands, feet)

139. ➜

Dry skin

140. ➜

Sensitivity to light

141. ➜

Fatigue after exercising (feeling worse)

142. ➜

Bad night vision or seeing halos around lifts

143. ➜

Shortness of breath, with very little effort

144. ➜

Excessive thirst and/or frequent urination

145. ➜

Red eyes or tearing

146. ➜

Blurred vision at times

147. ➜

Morning stiffness

148. ➜

Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners

149. ➜

Chronic fatigue or weakness

150. ➜

Non-restful sleep

151. ➜

Receive static shock more often and with more dramatic effect than normal (doorknobs, car, light switch, people..)

152. ➜

Trouble processing new information

153. ➜

Word reversal or trouble finding words

154. ➜

Sensitivity to touch

155. ➜

Short-term memory loss

156. ➜

Chronic Sinus congestion

157. ➜

Dry non-productive cough

158. ➜

Muscle twitching

159. ➜

Excessive sweating, especially at night

160. ➜

Heart pain (angina) and you are under 45yrs old

161. ➜

Depression

162. ➜

Gout (arthritic pain, especially in big toes)

163. ➜

Pain in shoulders or upper back

164. ➜

Twitching eyelids

165. ➜

Anemia (low iron/hemoglobin on blood test)

166. ➜

Wrist/ankle drop or weak extensor muscles

167. ➜

Hair falls out (not normal male pattern baldness)

168. ➜

Join pain-not necessarily true arthritis can move from joint to joint

169. ➜

Difficulty losing weight regardless of diet or exercise

170. ➜

Persistent fugal or viral infection, including athlete foot, warts, jock itch, candidiasis

171. ➜

Frequent illness, prolonged illness or sick days

172. ➜

Numbness or weakness in arms & legs

173. ➜

Headaches

174. ➜

Trouble adding or dividing numbers in your head

175. ➜

Fluctuating constipation & diarrhea

176. ➜

Stomach pain for no apparent reason

177. ➜

Appetite swings

178. ➜

Frequent muscle aches, cramps, unusual sharp sudden pains

179. ➜

Rashes or Resaca

180. ➜

Cold extremities (hands & feet)

181. ➜

Do you get the Covid Vaccine?

Yes

182. ➜

If Yes, How many?

183. ➜

Scoring:

Over 100: Severely neurotoxic; this patient is positive for neurotoxicity and undoubtedly needs Cellular Detox and will need to complete many brain phases to detox.

50-99: Neurotoxic; this patient is positive for neurotoxicity and needs Cellular Detox to decrease symptoms and improve overall health.

Less than 49: less toxic; this patient should still do Cellular Detox to increase vitality due to the ubiquitous neurotoxins in our modern world.

184. ➜

Thank you for Completing this Assessment. Please watch your email for information to schedule your review with our Certified Cellular Detoxification & Health Practitioner.

185. ➜

Save your answers

Enter your email address so we can save your answers for you:

Simplero

Country Root Healing

Neuro-Toxin Assessment

Information

Information

Statue

Live With

Occupation

How did you hear about our Wellness & Nutrition Program?

What is your major Complaint? Pease list when each symptom began and be as descriptive as possible:

What are your current Medications:

What is your current vitamin and/or supplements:

Please list your current and past health conditions (i.e. Diabetes Mellitus, etc):

Is there anything else in your medical history that you consider to be relevant? (Even from Childhood):

What is your employment history? Please provide brief summary including dates if possible:

Please list your past or present Hobbies that could be sources of toxicity or chemicals:

How often are you involved in these Hobbies currently:

Please list past or present allergies, including allergies to medications:

Please list all past surgeries and the condition each surgery was for, including dates:

Please explain your housing history (type of homes, where and when):

Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank.

Mercury

Do you have amalgam (silver) fillings in your teeth?

If so, How Many?

Have you ever had an amalgam removed?

If yes, How many & Date removed?

If you had amalgams removed, was it done by a biological dentist using a safe protocol?

Did your mother have amalgam when pregnant with you?

Have you ever worked in a dental office?

If so, How long?

Have you had any dental crowns?

If so, how many?

Have you had any bridges?

Have you had any root canals?

Have you had any tooth extractions?

Do you have any dental implants, retainers or other metal in your mouth?

Did you wear contact lenses during the 1980's or early 1990's?

Did you take oral contraceptives during the 1980's or early 1990's?

Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?

Have you noticed any adverse reactions to these shots?

Do you have any tattoos with red ink?

Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

Lead

Does your occupation involve soldering or metal salvage?

Have you done any old home repaid or sandblasting?

If so , when?

Do you do a lot of painting?

Was your home built before 1978?

Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)

Are you around a lot of fake leather, or vinyl?

Do you get stomach aches in the morning?

General Toxicity

Have you ever lived near, or or by a golf course, freeway or tension wires?

If yes, please explain:

Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)

Do you have your house sprayed with pesticides for pest control?

Do you spray herbicide (weed killers) in or around your home?

Do you use conventional insect repellants on your self or family?

Do you use conventional sunscreen?

Do you use conventional perfume or cologne every day?

Do you get your hair colored?

Do you use aerosol hairspray?

If so, how often?

Do you use air freshener in your house, work or car?

Do you drink filtered water?

Do you drink filtered water?

If so, what type of filter do you have?

Do you drink bottle water?

Do you have a water filtration system for your entire house or shower filtration?

Does your spouse or other family members work around chemicals?

Can you think of any other toxic exposures you may have had?

Molds

How old is the hour you are living in? How long have you lived there? Have you noticed symptoms since moving in? If so, what?

Do you see mold growing in your home, work or school?

Have you ever had water damage in your home, work or school?

Does you home, workplace or school have a damp or mildew smell?

Does spending time in your basement cause or worsen your symptoms?

Does your basement ever get wet?

Do you have a crawl space?

Does you basement or crawl space have a sump pump?

Does spending time ion a different location for at least a few days cause a noticeable decrease in your symptoms?