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  • Total Score: {survey_total_score} Section 1: {score:id=7} Section 2: {score:id=8} Section 3: {score:id=11} Section 4: {score:id=13}

  • Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year, or since the last time you completed a Neurotoxic Questionnaire. If you cannot answer a question, select N/A

    POINT SCALE:
    0 = Never had/have symptoms
    1 = Occasionally have it, mild effect
    2 = Occasionally have it, severe effect
    3 = Frequently have it, mild effect
    4 = Frequently have it, severe effect

  • Section 1

  • Remember: 0 is Not Severe, 4 is Very Severe
    01234N/A
    Anxiety
    Mood swings
    Enraged behavior or anger
    Excessive shyness, timidity, social phobia (not typical to personality)
    Irritability (not typical to personality)
    Low body temperature (below 97.3 F)
    Insomnia (can't go to sleep or return to sleep)
    Dizziness
    Sound in ears (ringing or hearing your heart beat)
    Psychological symptoms, even thoughts of suicide
    Sensitivity to sound

  • Section 2

  • Remember: 0 is Not Severe, 4 is Very Severe
    01234N/A
    Indecisiveness
    Feeling of being overwhelmed or fearful
    Metallic taste in your mouth
    Bad breath
    Bleeding gums
    Sensitive teeth
    Canker sores or other sores in mouth
    Floaters, shadows, or swimmers when you read or look into the sky
    Dyslexia or loss of place while reading, even as a child
    Swelling eyelids
    Peeling on the top layer of skin (hands, feet)
    Dry skin
    Heart pain (angina) and you are under 45 years old
    Depression
    Gout (arthritic pain, especially in big toes)
    Pain in shoulders or upper back
    Twitching eyelids
    Anemia
    Wrist/ankle drop or weak extensor muscles
    Hair falls out (not normal male pattern baldness)

  • Section 3

  • Remember: 0 is Not Severe, 4 is Very Severe
    01234N/A
    Sensitivity to light
    Fatigue after exercising (feeling worse)
    Bad night vision or seeing halos around lights
    Shortness of breath, with very little effort
    Excessive thirst and/or frequent urination
    Red eyes or tearing
    Blurred vision at times
    Morning stiffness
    Sensitivity to smells (chemicals such as petrochemicals, perfumes, air fresheners)
    Chronic fatigue or weakness
    Non-restful sleep

  • Section 4

  • Remember: 0 is Not Severe, 4 is Very Severe
    01234N/A
    Receive static shock more often & with more dramatic effect than normal
    Trouble processing new information
    Word reversal or trouble finding words
    Sensitivity to touch
    Short-term memory loss
    Chronic sinus congestion
    Dry, non-productive cough
    Muscle twitching
    Excessive sweating, especially at night
    Joint pain - not necessarily true arthritis - can move from joint to joint
    Difficulty losing weight regardless of diet or exercise
    Persistent fungal or viral infection, including athlete's foot, warts, jock itch, candida
    Frequent illness, prolonged illness or sick days
    Numbness or weakness in arms and legs
    Headaches
    Trouble adding or dividing numbers in your head
    Fluctuating constipation and diarrhea
    Stomach pain for no apparent reason
    Appetite swings
    Frequent muscle aches, cramps, unusual sharp sudden pains
    Rashes or rosacea
    Cold extremities (hands and feet)