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Worksheet

Neuro-Toxin Assessment

🚨 Is Neurotoxicity Holding You Back? Take the First Step to Reclaim Your Health! 🚨

Brain fog, chronic fatigue, headaches, anxiety, and stubborn weight gain—these could all be signs of hidden neurotoxicity wreaking havoc on your body. Toxins from mold, heavy metals, pesticides, and everyday chemicals can silently disrupt your brain and nervous system, leaving you feeling drained and unwell.

🔎 Our Neurotoxicity Assessment helps uncover the root cause of your symptoms so we can take control of your health. Don’t let hidden toxins dictate how you feel—get the answers you need today!

📋 Please Be Sure to Answer ALL QUESTIONS that Apply 💞

All your information is kept confidential.

We will be reaching out to you soon to review your results...  Please allow 1-3 days to review and build your personalized Plan.

1. ➜

1. Information

Names:

Address:

Phone#:

Date of Birth:


2. ➜

2. Information

Email Address:

Gender:  Male or Female

Height & Weight:

3. ➜

3. Statue

4. ➜

4. Live With

5. ➜

5. Occupation

Name of Employer:  Hours per Week Worked:  

6. ➜

6. How did you hear about our Wellness & Nutrition Program?

7. ➜

7. What is your major Complaint?  Pease list when each symptom began and be as descriptive as possible:

8. ➜

8. What are your current Medications:

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9. What is your current vitamin and/or supplements:

10. ➜

10. Please list your current and past health conditions (i.e. Diabetes Mellitus, etc):

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11. Is there anything else in your medical history that you consider to be relevant? (Even from Childhood):

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12. What is your employment history? Please provide brief summary including dates if possible:

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13. Please list your past or present Hobbies that could be sources of toxicity or chemicals:

14. ➜

14. How often are you involved in these Hobbies currently:

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15. Please list past or present allergies, including allergies to medications:

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16. Please list all past surgeries and the condition each surgery was for, including dates:

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17. Please explain your housing history (type of homes, where and when):

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18. Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank.

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🌿Mercury

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20. ➜

19. Do you have amalgam (silver) fillings in your teeth?

21. ➜

20. If so, How Many?

22. ➜

21. Have you ever had an amalgam removed?

23. ➜

22. If yes, How many & Date removed?

24. ➜

23. If you had amalgams removed, was it done by a biological dentist using a safe protocol?

25. ➜

24. Did your mother have amalgam when pregnant with you?

26. ➜

25. Have you ever worked in a dental office?

27. ➜

26. If so, How long?

28. ➜

27. Have you had any dental crowns?

29. ➜

28. If so, how many?

30. ➜

29. Have you had any bridges?

31. ➜

30. Have you had any root canals?

32. ➜

31. Have you had any tooth extractions?

33. ➜

32. Do you have any dental implants, retainers or other metal in your mouth?

34. ➜

33. Did you wear contact lenses during the 1980's or early 1990's?

35. ➜

34. Did you take oral contraceptives during the 1980's or early 1990's?

36. ➜

35. Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?

37. ➜

36. Have you noticed any adverse reactions to these shots?

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37. Do you have any tattoos with red ink?

39. ➜

38. Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

40. ➜

🪢Lead

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41. ➜

39. Does your occupation involve soldering or metal salvage?

42. ➜

40. Have you done any old home repaid or sandblasting?

43. ➜

41. If so , when?

44. ➜

42. Do you do a lot of painting?

45. ➜

44. Was your home built before 1978?

46. ➜

45. Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)

47. ➜

46. Are you around a lot of fake leather, or vinyl?

48. ➜

47. Do you get stomach aches in the morning?

49. ➜

✨General Toxicity

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50. ➜

48. Have you ever lived near, or or by a golf course, freeway or tension wires?

51. ➜

49. If yes, please explain:

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50. Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)

53. ➜

51. Do you have your house sprayed with pesticides for pest control?

54. ➜

52. Do you spray herbicide (weed killers) in or around your home?

55. ➜

53. Do you use conventional insect repellants on your self or family?

56. ➜

54. Do you use conventional sunscreen?

57. ➜

55. Do you use conventional perfume or cologne every day?

58. ➜

56. Do you get your hair colored?

59. ➜

57. Do you use aerosol hairspray?

60. ➜

58. If so, how often?

61. ➜

59. Do you use air freshener in your house, work or car?

62. ➜

60. Do you drink filtered water?

63. ➜

61. If so, what type of filter do you have?

64. ➜

62. Do you drink bottle water?

65. ➜

63. Do you have a water filtration system for your entire house or shower filtration?

66. ➜

64. Does your spouse or other family members work around chemicals?

67. ➜

65. Can you think of any other toxic exposures you may have had?

68. ➜

💥Molds

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69. ➜

66. How old is the house you are living in? How long have you lived there? Have you noticed symptoms since moving in? If so, what?

70. ➜

67. Do you see mold growing in your home, work or school?

71. ➜

68. Have you ever had water damage in your home, work or school?

72. ➜

69. Does you home, workplace or school have a damp or mildew smell?

73. ➜

70. Does spending time in your basement cause or worsen your symptoms?

74. ➜

71. Does your basement ever get wet?

75. ➜

72. Do you have a crawl space?

76. ➜

73. Does you basement or crawl space have a sump pump?

77. ➜

74. Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?

78. ➜

75. Does your car have a mildew smell?

79. ➜

76. Does anyone in your home have asthma like symptoms?

80. ➜

77. Does anyone in your family have chronic sinus infections or irritations?

81. ➜

🧸 Lyme Disease

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82. ➜

78. Have you ever been diagnosed with Lyme Disease?

83. ➜

79. Have you had dry sockets or infected tooth extractions?

84. ➜

80. Do you have small joint pain?

85. ➜

81. Have you ever been bitten by a tick or recluse spider?

86. ➜

82. Have you ever seen a bulls-eyes rash appear on any part of your body?

87. ➜

83. Did the bulls-eyes rash appear shortly after following a tick, spider bits or time spent outdoors?

88. ➜

84. Was your mother ever diagnosed with Lyme Disease?

89. ➜

85. Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition?

90. ➜

86. Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

91. ➜

💖Health History

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92. ➜

87. Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

93. ➜

88. Does anyone in your family experience similar symptoms to yours?

94. ➜

89. What is your birth order (i.e. First born, second, third, etc.)?

95. ➜

90. Do you have any history of kidney dysfunction?

96. ➜

91. Do you or any immediate family member have a history with cancer?

97. ➜

92. Do you have any history of heart disease, myocardial infarction (heart attack), etc.?

98. ➜

93. Are you currently having any thoughts of suicide?

99. ➜

94. Have you every been diagnosed with bipolar disorder, schizophrenia or depression?

100. ➜

95. Do you have a history of strokes?

101. ➜

96. Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?

102. ➜

97. Have you ever been in an auto accident, fallen or received a major physical injury?

103. ➜

98. Are you in menopause?

104. ➜

🪢Microbiome Health

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105. ➜

99. Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, brussels sprouts or other vegetables?

106. ➜

100. Do you often have gas that has a sulfur or foul smell?

107. ➜

101. Are you sensitive to supplements?

108. ➜

102. Have you ever been vegan or vegetarian for any length of time?

109. ➜

103. Can you tolerate Meat?

110. ➜

104. Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?

111. ➜

105. Have you taken birth control or hormone replacement therapy for any length of time?

112. ➜

106. If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

113. ➜

107. Have been on antibiotics for any extended period of time or often as a child or adult?

114. ➜

108. Were you caesarian delivered?

115. ➜

109. Were you breast fed?

116. ➜

110. Do you temporarily feel better after a round of antibiotics?

117. ➜

111. How many times a day are you having a bowel movement?

118. ➜

🚦Rate Symptoms

Rate each of the following symptom to the best of your ability based upon your typical health profile over the last year.  If you cannot answer a question, simply leave it blank.

0 = Never had the symptom          2 = Occasionally have it, severe effect     4 = Frequently have it, severe effect


1 = Occasionally have it, mild effect               3 = Frequently have it, mild effect

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119. ➜

112. Anxiety

120. ➜

113. Mood swings

121. ➜

114. Enraged behavior or anger for no reason

122. ➜

115. Excessive shyness, timidity, social phobia (not typical to your personality)

123. ➜

116. Irritability (not typical to your personality)

124. ➜

117. Low body temperature (below 97.5)

125. ➜

118. Insomnia (can't get to sleep or return to sleep)

126. ➜

119. Dizziness

127. ➜

120. Sound in ears (ringing or hearing your heart beat)

128. ➜

121. Psychological symptoms, even thoughts of suicide

129. ➜

122. Sensitivity to sound

130. ➜

123. Indecisiveness feeling of being overwhelmed or fearful

131. ➜

124. Metallic taste in your mouth

132. ➜

125. Bad breath, Bleeding gums, Sensitive teeth

133. ➜

126. Canker sores or other sores in the mouth

134. ➜

127. Floaters, shadows or swimmers when you read or look into the sky

135. ➜

128. Dyslexia or loss of place while reading, even as a child

136. ➜

129. Swelling eyelids

137. ➜

130. Peeling on top layer of skin (hands, feet)

138. ➜

131. Dry skin

139. ➜

132. Sensitivity to light

140. ➜

133. Fatigue after exercising (feeling worse)

141. ➜

134. Bad night vision or seeing halos around lifts

142. ➜

135. Shortness of breath, with very little effort

143. ➜

136. Excessive thirst and/or frequent urination

144. ➜

137. Red eyes or tearing

145. ➜

138. Blurred vision at times

146. ➜

139. Morning stiffness

147. ➜

140. Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners

148. ➜

141. Chronic fatigue or weakness

149. ➜

142. Non-restful sleep

150. ➜

143. Receive static shock more often and with more dramatic effect than normal (doorknobs, car, light switch, people..)

151. ➜

144. Trouble processing new information

152. ➜

145. Word reversal or trouble finding words

153. ➜

146. Sensitivity to touch

154. ➜

147. Short-term memory loss

155. ➜

148. Chronic Sinus congestion

156. ➜

149. Dry non-productive cough

157. ➜

150. Muscle twitching

158. ➜

151. Excessive sweating, especially at night

159. ➜

152. Heart pain (angina) and you are under 45yrs old

160. ➜

153. Depression

161. ➜

154. Gout (arthritic pain, especially in big toes)

162. ➜

155. Pain in shoulders or upper back

163. ➜

156. Twitching eyelids

164. ➜

157. Anemia (low iron/hemoglobin on blood test)

165. ➜

158. Wrist/ankle drop or weak extensor muscles

166. ➜

159. Hair falls out (not normal male pattern baldness)

167. ➜

160. Join pain-not necessarily true arthritis can move from joint to joint

168. ➜

161. Difficulty losing weight regardless of diet or exercise

169. ➜

162. Persistent fugal or viral infection, including athlete foot, warts, jock itch, candidiasis

170. ➜

163. Frequent illness, prolonged illness or sick days

171. ➜

164. Numbness or weakness in arms & legs

172. ➜

165. Headaches

173. ➜

166. Trouble adding or dividing numbers in your head

174. ➜

167. Fluctuating constipation & diarrhea

175. ➜

168. Stomach pain for no apparent reason

176. ➜

169. Appetite swings

177. ➜

170. Frequent muscle aches, cramps, unusual sharp sudden pains

178. ➜

171. Rashes or Resaca

179. ➜

172. Cold extremities (hands & feet)

180. ➜

173. Do you get the Covid Vaccine?

181. ➜

174. If Yes, How many?

182. ➜

💞Scoring:

Over 100:  Severely neurotoxic; this patient is positive for neurotoxicity and undoubtedly needs Cellular Detox and will need to complete many brain phases to detox.

50-99:  Neurotoxic; this patient is positive for neurotoxicity and needs Cellular Detox to decrease symptoms and improve overall health.

Less than 49:  less toxic; this patient should still do Cellular Detox to increase vitality due to the ubiquitous neurotoxins in our modern world.

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183. ➜

Thank you for Completing this Assessment.

Please give me 1-3 days to review your assessment to map at the plan for you.   Watch your email for information to schedule your review with our Certified Cellular Detoxification & Health Practitioner.


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