TOXICITY & SYMPTOMS QUESTIONNAIRE

TOXICITY & SYMPTOMS QUESTIONNAIRE
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This Toxicity & Symptoms Questionnaire identifies symptoms that help to reveal the underlying causes of illness, and helps you track your progress over time. Please be as honest as you can about your symptoms. Before starting the RESTART Program, please rate each of the following symptoms based upon your health profile for the past 30 days. In Week Five of RESTART, this questionnaire will be completed again at that time please record your symptoms for the previous three weeks only. Each time you submit a form you will receive an email recording your selections and score. Your instructor will receive just an email recording your name, date, and score no other details will be included.
Point Scale
0 = Never, or almost never have the symptom
1 = Occasionally have it, the effect is NOT severe
2 = Occasionally have it, the effect is severe
3 = Frequently have it, the effect is NOT severe
4 = Frequently have it, the effect is severe
DIGESTIVE TRACT
Nausea or vomiting

0 1 2 3 4
0 is None, 4 is Frequent/severe
Diarrhea

0 1 2 3 4
0 is None, 4 is Frequent/severe
Constipation

0 1 2 3 4
0 is None, 4 is Frequent/severe
Bloated feeling

0 1 2 3 4
0 is None, 4 is Frequent/severe
Belching or passing gas

0 1 2 3 4
0 is None, 4 is Frequent/severe
Heartburn

0 1 2 3 4
0 is None, 4 is Frequent/severe
Intestinal/ Stomach pain

0 1 2 3 4
0 is None, 4 is Frequent/severe
Digestive Tract Total
MOUTH / THROAT
Chronic Coughing

0 1 2 3 4
0 is None, 4 is Frequent/severe
Canker sores

0 1 2 3 4
0 is None, 4 is Frequent/severe
Sore throat, loss of voice, hoarseness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Gagging, frequent need to clear throat

0 1 2 3 4
0 is None, 4 is Frequent/severe
Swollen/discolored tongue, gum, lips

0 1 2 3 4
0 is None, 4 is Frequent/severe
Mouth/Throat Total
HEAD
Headaches

0 1 2 3 4
0 is None, 4 is Frequent/severe
Faintess

0 1 2 3 4
0 is None, 4 is Frequent/severe
Dizziness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Insomnia

0 1 2 3 4
0 is None, 4 is Frequent/severe
Head Total
EARS
Itchy ears

0 1 2 3 4
0 is None, 4 is Frequent/severe
Earaches, ear infections

0 1 2 3 4
0 is None, 4 is Frequent/severe
Drainage from ear

0 1 2 3 4
0 is None, 4 is Frequent/severe
Ringing in ears, hearing loss

0 1 2 3 4
0 is None, 4 is Frequent/severe
Ears Total
HEART
Irregular or skipped heartbeat

0 1 2 3 4
0 is None, 4 is Frequent/severe
Rapid or pounding heartbeat

0 1 2 3 4
0 is None, 4 is Frequent/severe
Chest pain

0 1 2 3 4
0 is None, 4 is Frequent/severe
Heart Total
NOSE
Stuffy nose

0 1 2 3 4
0 is None, 4 is Frequent/severe
Sinus problems

0 1 2 3 4
0 is None, 4 is Frequent/severe
Hay fever

0 1 2 3 4
0 is None, 4 is Frequent/severe
Sneezing attacks

0 1 2 3 4
0 is None, 4 is Frequent/severe
Excessive mucus formation

0 1 2 3 4
0 is None, 4 is Frequent/severe
Nose Total
EMOTIONS
Mood swings

0 1 2 3 4
0 is None, 4 is Frequent/severe
Anxiety, fear or nervousness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Anger, irritability, or aggressiveness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Depression

0 1 2 3 4
0 is None, 4 is Frequent/severe
Emotions Total
JOINTS / MUSCLES
Pain or aches in joints

0 1 2 3 4
0 is None, 4 is Frequent/severe
Arthritis

0 1 2 3 4
0 is None, 4 is Frequent/severe
Pain or aches in muscles

0 1 2 3 4
0 is None, 4 is Frequent/severe
Feeling of weakness or tiredness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Stiffness or limitation of movement

0 1 2 3 4
0 is None, 4 is Frequent/severe
Joint/Muscles Total
SKIN
Acne

0 1 2 3 4
0 is None, 4 is Frequent/severe
Hair loss

0 1 2 3 4
0 is None, 4 is Frequent/severe
Hives, rashes, or dry skin

0 1 2 3 4
0 is None, 4 is Frequent/severe
Flushing or hot flushes

0 1 2 3 4
0 is None, 4 is Frequent/severe
Excessive sweating

0 1 2 3 4
0 is None, 4 is Frequent/severe
Skin Total
ENERGY / ACTIVITY
Fatigue, sluggishness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Apathy, lethargy

0 1 2 3 4
0 is None, 4 is Frequent/severe
Hyperactivity

0 1 2 3 4
0 is None, 4 is Frequent/severe
Restlessness

0 1 2 3 4
0 is None, 4 is Frequent/severe
Energy/Activity Total
LUNGS
Chest congestion

0 1 2 3 4
0 is None, 4 is Frequent/severe
Asthma, bronchitis

0 1 2 3 4
0 is None, 4 is Frequent/severe
Shortness of breath

0 1 2 3 4
0 is None, 4 is Frequent/severe
Difficult breathing

0 1 2 3 4
0 is None, 4 is Frequent/severe
Lungs Total
WEIGHT
Binge eating/drinking

0 1 2 3 4
0 is None, 4 is Frequent/severe
Craving certain foods

0 1 2 3 4
0 is None, 4 is Frequent/severe
Excessive weight

0 1 2 3 4
0 is None, 4 is Frequent/severe
Compulsive eating

0 1 2 3 4
0 is None, 4 is Frequent/severe
Water retention

0 1 2 3 4
0 is None, 4 is Frequent/severe
Underweight

0 1 2 3 4
0 is None, 4 is Frequent/severe
Weight Total
EYES
Watery or itchy eyes

0 1 2 3 4
0 is None, 4 is Frequent/severe
Swollen, reddened or sticky eyelids

0 1 2 3 4
0 is None, 4 is Frequent/severe
Bags or dark circles under eyes

0 1 2 3 4
0 is None, 4 is Frequent/severe
Blurred or tunnel vision (does not include near-or far-sightedness)

0 1 2 3 4
0 is None, 4 is Frequent/severe
Eyes Total
MIND
Poor memory

0 1 2 3 4
0 is None, 4 is Frequent/severe
Confusion, poor comprehension

0 1 2 3 4
0 is None, 4 is Frequent/severe
Poor concentration

0 1 2 3 4
0 is None, 4 is Frequent/severe
Poor physical coordination

0 1 2 3 4
0 is None, 4 is Frequent/severe
Difficulty in making decisions

0 1 2 3 4
0 is None, 4 is Frequent/severe
Stuttering or stammering

0 1 2 3 4
0 is None, 4 is Frequent/severe
Slurred speech

0 1 2 3 4
0 is None, 4 is Frequent/severe
Learning disabilities

0 1 2 3 4
0 is None, 4 is Frequent/severe
Mind Total
OTHER
Frequent illness

0 1 2 3 4
0 is Never, 4 is Frequent/severe
Frequent or urgent urination

0 1 2 3 4
0 is Never, 4 is Frequent/severe
Genital itch or discharge

0 1 2 3 4
0 is Never, 4 is Frequent/severe
Other Total
Your Results:
Less than 10 = Optimal 10 - 50 = Mild Toxicity 51 - 100 = Moderate Toxicity Over 100 = Severe Toxicity
GRAND TOTAL
Should be Empty:

TOXICITY & SYMPTOMS QUESTIONNAIRE

DIGESTIVE TRACT

MOUTH / THROAT

HEAD

EARS

HEART

NOSE

EMOTIONS

JOINTS / MUSCLES

SKIN

ENERGY / ACTIVITY

LUNGS

WEIGHT

EYES

MIND

OTHER