Medical screening questionnaire

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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

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

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