Toxicity Questionnaire | Dr. Katharina Johnson

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.


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

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

Section 1: Symptoms

1. Digestive

2. Ears

3. Emotions

4. Energy/Activity

5. Eyes

6. Head

7. Lungs

8. Mind

9. Mouth/Throat

10. Nose

11. Skin

12. Heart

13. Joints/Muscles

14. Weight

15. Other

Section 2: Exposure

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