CIRS and BioToxins Questionnaire
Today's Date
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Day
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Month
Year
Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Are you a current NatMed Patient?
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Yes
No
Please tick if you have any of the below symptoms. Please tick the box even if you only semi-regularly experience the symptom.
Section #1
Fatigue
Section #2
Weakness
Decreased assimilation of new Ideas
Aches
Light Sensitivity
Section #3
Memory Impairment
Decreased Word Finding
Question #4
Difficulty Concentrating
Section #5
Joint Pain
Stiffness in the Morning
Cramps
Section #6
Tingling
Tremors
Unusual Pain
Unusual Skin Sensations
Section #7
Shortness of Breath
Sinus Congestion
Section #8
Cough
Excessive Thirst
Confusion
Section #9
Apetite Swings
Difficulty regulating body temperature
Increased urinary frequency
Section #10
Red Eyes
Blurred Vision
Night Sweats
Mood Swings
Ice-Pick Pains
Section #11
Abdominal Pain
Diarrhoea
Numbness
Section #12
Tearing of Eyes
Disorientation
Metallic Taste
Section #13
Static Shocks
Vertigo
Number of Boxes Ticked:
Number of Sections that you have ANY ticked boxes
OutComes
A score of 8 or more of the 13 sections is considered diagnostic (98.4% sensitivity in adults)
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Thank you. We are proud to support you on your journey to empower you to create the health you deserve.
Want to know more about the condition we're screening for with this questionnaire? Read more on our dedicated CIRS page here: https://natmed.com.au/cirs/
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