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Am I Toxic (Initial Assessment)

Are You Toxic and/or Inflamed?

Baseline - Initial Assessment. 

 

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Question 1 of 34

Body Odor

A

No

B

Yes

Question 2 of 34

Bad Breath

A

No

B

Yes

Question 3 of 34

A coating on your tongue that does not scrape/brush off with your toothbrush or fingernail.

A

No

B

Yes

Question 4 of 34

Hair loss more than usual, dandruff or itchy scalp

A

No

B

Yes

Question 5 of 34

Skin issues: acne (cystic or otherwise), eczema, rashes, itchy skin, and/or flaky

A

No

B

Yes

Question 6 of 34

Eyesight changes (may not just be "aging eyes')

A

No

B

Yes

Question 7 of 34

Decreased sense of smell or taste (even when others easily can smell/taste something)

A

I do notice smells/tastes easily

B

I do not notice smells/tastes easily

Question 8 of 34

Swollen in face, hands, legs, ankles, and/or feet

A

No

B

Yes

Question 9 of 34

Shortness of breath during and soreness after nearly any activity

A

No

B

Yes

Question 10 of 34

Generally feel unwell / weakness

A

No

B

Yes

Question 11 of 34

Belly aches/Nausea/Vomiting/Vurping (wet burps)

A

No

B

Yes

Question 12 of 34

Sugar/Carb Cravings

A

No

B

Yes

Question 13 of 34

Pain/tenderness in upper right abdomen often (like a "stitch" in the side)

A

No

B

Yes

Question 14 of 34

Strong urine odor and/or yellow to dark amber colored urine throughout the day.

A

No

B

Yes

Question 15 of 34

Diarrhea, constipation, and/or bloating

A

No

B

Yes

Question 16 of 34

My poop floats (yes, that's a sign) and/or is slimy (looks like fatty globs) with mucus, noticeably extra smelly, and/or is sticky/tarry and difficult to wipe.

A

No

B

Yes

Question 17 of 34

I typically wake between 1-4am many/most nights and/or have to go to the bathroom during the night.

A

No

B

Yes

Question 18 of 34

Fatigue, trouble staying alert/awake, tired more than usual even after sleeping.

A

No

B

Yes

Question 19 of 34

Unable to go to sleep or stay asleep, hypervigilant, startle easily, jumpy, sharp, nightmares, flashbacks.

A

No

B

Yes

Question 20 of 34

Chronic Pain: Headaches/Migraines, joint aches, pain, swollen

A

No

B

Yes

Question 21 of 34

Foggy Brain, memory loss, memory recall issues, decreased concentration

A

No

B

Yes

Question 22 of 34

Experience emotional overwhelm, panic/anxiety attacks, dissociation (check out/escape in your mind, disconnect from the world around you when something bothers you) loss of interest in things that used to be enjoyable 

A

No

B

Yes

Question 23 of 34

Moody (Overly Excited, happy, then Short Tempered, Stressed, Irritable, Anxious, Depressed, Hopeless)

A

No

B

Yes

Question 24 of 34

Change in appetite (loss or increase)

A

No

B

Yes

Question 25 of 34

Eating disorders (too much or too little)

A

No

B

Yes

Question 26 of 34

Nutritional deficiencies/poor lab results (per Dr/labs)

A

No

B

Yes

Question 27 of 34

Chronic Ailments/Illness/Sickness - can't seem to catch a break

A

No

B

Yes

Question 28 of 34

Menstrual/hormonal Issues

A

No

B

Yes

C

Not Applicable

Question 29 of 34

Libido/Sex Drive/Hormonal Issues

A

No

B

Yes

Question 30 of 34

 Self destructive, self sabotaging behaviors, substance use to feel better/numb.

A

No

B

Yes

Question 31 of 34

Self hatred and hate of others, a lot of guilt, shame, and blame thoughts.

A

No

B

Yes

Question 32 of 34

My trusted partner/friends have told me I'm toxic (or noticed any of the above) ;)

A

No

B

Yes

Question 33 of 34

My health professional has voiced concerns regarding my health

A

No

B

Yes

Question 34 of 34

I possibly have unrecognized (or undealt with) trauma that may be impacting my health.  I have experienced: 

(Select all that apply)
A

A vehicle accident

B

Medical Trauma (surgery, procedure, unpleasant medication side effects, etc)

C

Physical Assault/Physical Harm

D

Physical Abuse

E

Sexual Abuse/Rape/Molestation (groping/fondling without consent or when asked to stop counts)

F

Childhood Neglect

G

Crime (against myself or against someone else)

H

Death of a significant person

I

Divorce/Separation/Break Up with someone significant

J

Infidelity/Disloyalty of someone significant

K

Intimate Partner Violence

L

Miscarriage/Loss of a Pregnancy

M

Military Combat

N

Natural Disaster (tornado, hurricane, flood, earthquake, fire, etc)

O

I believe so many negative thoughts about myself often because harm has been done to me (or by me) that keeps me stuck in fear/doubt that makes me believe I cannot overcome it. (Harm may be a compilation of demeaning or discrediting words, social exclusion, physical, mental, and/or emotional misuse, religious, or parental/partner fear tactics, etc. Anything that made you feel less than or incapable to overcome them.)

P

None of the Above

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