Toxicity Questionnaire | Dr. Katharina Johnson

Toxicity Questionnaire

Please take your time to fill this out. It takes approximately 5 minutes. I will get back to you within 3 business days to let you know about your results. All information provided by you will be kept confidential. Your email address will not be shared with a third party.


Name:
Email Address:

Section 1: Symptoms
Rate each of the following based on your health for the last 90 days. Select the corresponding number for the questions below. 0 Rarely or Never Experience the symptom 1 Occasionally Experience the symptom, effect is Not Severe 2 Occasionally Experience the symptom, effect is Severe 3 Frequently Experience the symptom, effect is Not Severe 4 Frequently Experience the symptom, effect is Severe


1. Digestive
a. Nausea and/or vomiting	0 1 2 3 4
b. Diarrhea	0 1 2 3 4
c. Constipation	0 1 2 3 4
d. Bloated feeling	0 1 2 3 4
e. Belching and/or passing gas	0 1 2 3 4
f. Heartburn	0 1 2 3 4
2. Ears
a. Itchy Ears	0 1 2 3 4
b. Earaches or ear infections	0 1 2 3 4
c. Drainage from ear	0 1 2 3 4
d. Ringing in ears or hearing loss	0 1 2 3 4
3. Emotions
a. Mood swings	0 1 2 3 4
b. Anxiety, fear or nervousness	0 1 2 3 4
c. Anger, irritability	0 1 2 3 4
d. Depression	0 1 2 3 4
e. Sense of despair	0 1 2 3 4
f. Uncaring or disinterest	0 1 2 3 4
4. Energy/Activity
a. Fatigue or sluggishness	0 1 2 3 4
b. Hyperactivity	0 1 2 3 4
c. Restlessness	0 1 2 3 4
d. Insomnia	0 1 2 3 4
e. Startled awake at night	0 1 2 3 4
5. Eyes
a. Watery or itchy eyes	0 1 2 3 4
b. Swollen, reddened or sticky eyelids	0 1 2 3 4
c. Dark circles under eyes	0 1 2 3 4
d. Blurred or tunnel vision	0 1 2 3 4
6. Head
a. Headaches	0 1 2 3 4
b. Faintness	0 1 2 3 4
c. Dizziness	0 1 2 3 4
d. Pressure	0 1 2 3 4
7. Lungs
a. Chest congestion	0 1 2 3 4
b. Asthma or bronchitis	0 1 2 3 4
c. Shortness of breath	0 1 2 3 4
d. Difficulty breathing	0 1 2 3 4
8. Mind
a. Poor memory	0 1 2 3 4
b. Confusion	0 1 2 3 4
c. Poor concentration	0 1 2 3 4
d. Poor coordination	0 1 2 3 4
e. Difficulty making decisions	0 1 2 3 4
f. Stuttering, stammering	0 1 2 3 4
g. Slurred speech	0 1 2 3 4
h. Learning disabilities	0 1 2 3 4
9. Mouth/Throat
a. Chronic coughing	0 1 2 3 4
b. Gagging or frequent need to clear throat	0 1 2 3 4
c. Swollen or discolored tongue, gums, lips	0 1 2 3 4
d. Canker sores	0 1 2 3 4
10. Nose
a. Stuffy nose	0 1 2 3 4
b. Sinus problems	0 1 2 3 4
c. Hay fever	0 1 2 3 4
d. Sneezing attacks	0 1 2 3 4
e. Excessive mucous	0 1 2 3 4
11. Skin
a. Acne	0 1 2 3 4
b. Hives, rashes or dry skin	0 1 2 3 4
c. Hair loss	0 1 2 3 4
d. Flushing	0 1 2 3 4
e. Excessive sweating	0 1 2 3 4
12. Heart
a. Skipped heartbeat	0 1 2 3 4
b. Rapid heartbeats	0 1 2 3 4
c. Chest pain	0 1 2 3 4
13. Joints/Muscles
a. Pain or aches in joints	0 1 2 3 4
b. Rheumatoid arthritis	0 1 2 3 4
c. Osteoarthritis	0 1 2 3 4
d. Stiffness or limited movement	0 1 2 3 4
e. Pain or aches in muscles	0 1 2 3 4
f. Recurrent back aches	0 1 2 3 4
g. Feeling of weakness or tiredness	0 1 2 3 4
14. Weight
a. Binge eating or drinking	0 1 2 3 4
b. Craving certain foods	0 1 2 3 4
c. Excessive weight	0 1 2 3 4
d. Compulsive eating	0 1 2 3 4
e. Water retention	0 1 2 3 4
f. Underweight	0 1 2 3 4
15. Other
a. Frequent illness	0 1 2 3 4
b. Frequent or urgent urination	0 1 2 3 4
c. Leaky bladder	0 1 2 3 4
d. Genital itch, discharge	0 1 2 3 4

Section 2: Exposure
Rate each of the following based on your health for the last 120 days. Select the corresponding number for the questions below. 0 Never \| 1 Rarely \| 2 Monthly \| 3 Weekly \| 4 Daily


a. How often are stong chemicals used in your home? (disinfectants, bleaches, oven and drain cleaners, furniture polish, floor wax, window cleaners, etc.)	0 1 2 3 4
b. How often are pesticides used in your home?	0 1 2 3 4
c. How often do you have your home treated for insects?	0 1 2 3 4
d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense or varnish in your home or office?	0 1 2 3 4
e. How often are you exposed to nail polish, perfume, hair spray or other cosmetics?	0 1 2 3 4
f. How often are you exposed to diesel fumes, exhaust fumes or gasoline fumes?	0 1 2 3 4


Select the corresponding number for the questions below. 0 No \| 1 Mild Change \| 2 Moderate Change \| 3 Drastic Change


a. Have you noticed any negative change in your health since you moved into your home or apartment?	0 1 2 3
b. Have you noticed any negative changes in your health since you started your new job?	0 1 2 3


Select the corresponding number for the questions below.


	No \| Yes
a. Do you have a water purification system in your home?	2 0
b. Do you have any indoor pets?	0 2
c. Do you have an air purification system in you home?	2 0
d. Are you a dentist, painter, farm worker or construction worker?	0 2

Additional Information
Please add any additional comments about your health that you believe may be relevant.

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