0%
Worksheet

Neuro-Toxin Assessment

1. ➜

Information

Names:

Address:

Phone#:

Date of Birth:


2. ➜

Information

Email Address:

Gender:  Male or Female

Height & Weight:

3. ➜

Statue

4. ➜

Live With

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?

21. ➜

If so, How Many?

22. ➜

Have you ever had an amalgam removed?

23. ➜

If yes, How many & Date removed?

24. ➜

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

25. ➜

Did your mother have amalgam when pregnant with you?

26. ➜

Have you ever worked in a dental office?

27. ➜

If so, How long?

28. ➜

Have you had any dental crowns?

29. ➜

If so, how many?

30. ➜

Have you had any bridges?

31. ➜

Have you had any root canals?

32. ➜

Have you had any tooth extractions?

33. ➜

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

34. ➜

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

35. ➜

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

36. ➜

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

37. ➜

Have you noticed any adverse reactions to these shots?

38. ➜

Do you have any tattoos with red ink?

39. ➜

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

40. ➜

Lead

41. ➜

Does your occupation involve soldering or metal salvage?

42. ➜

Have you done any old home repaid or sandblasting?

43. ➜

If so , when?

44. ➜

Do you do a lot of painting?

45. ➜

Was your home built before 1978?

46. ➜

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

47. ➜

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

48. ➜

Do you get stomach aches in the morning?

49. ➜

General Toxicity

50. ➜

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

51. ➜

If yes, please explain:

52. ➜

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

53. ➜

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

54. ➜

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

55. ➜

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

56. ➜

Do you use conventional sunscreen?

57. ➜

Do you use conventional perfume or cologne every day?

58. ➜

Do you get your hair colored?

59. ➜

Do you use aerosol hairspray?

60. ➜

If so, how often?

61. ➜

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

62. ➜

Do you drink filtered water?

63. ➜

Do you drink filtered water?

64. ➜

If so, what type of filter do you have?

65. ➜

Do you drink bottle water?

66. ➜

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

67. ➜

Does your spouse or other family members work around chemicals?

68. ➜

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

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?

72. ➜

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

73. ➜

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

74. ➜

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

75. ➜

Does your basement ever get wet?

76. ➜

Do you have a crawl space?

77. ➜

Does you basement or crawl space have a sump pump?

78. ➜

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

79. ➜

Does your car have a mildew smell?

80. ➜

Does anyone in your home have asthma like symptoms?

81. ➜

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

82. ➜

Lyme Disease

83. ➜

Have you ever been diagnosed with Lyme Disease?

84. ➜

Have you had dry sockets or infected tooth extractions?

85. ➜

Do you have small joint pain?

86. ➜

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

87. ➜

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

88. ➜

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

89. ➜

Was your mother ever diagnosed with Lyme Disease?

90. ➜

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

91. ➜

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

92. ➜

Health History

93. ➜

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

94. ➜

Does anyone in your family experience similar symptoms to yours?

95. ➜

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

96. ➜

Do you have any history of kidney dysfunction?

97. ➜

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

98. ➜

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

99. ➜

Are you currently having any thoughts of suicide?

100. ➜

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

101. ➜

Do you have a history of strokes?

102. ➜

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

103. ➜

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

104. ➜

Are you in menopause?

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?

107. ➜

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

108. ➜

Are you sensitive to supplements?

109. ➜

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

110. ➜

Can you tolerate Meat?

111. ➜

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

112. ➜

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

113. ➜

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

114. ➜

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

115. ➜

Were you caesarian delivered?

116. ➜

Were you breast fed?

117. ➜

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

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?

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. ➜