2280 East Avenue, Suite 4, Rochester, New York 14610, United States
The Toxicity Questionnaire
Point scale:
Point scale:
Point scale:
- 0 = never or almost never have the symptom
- 1 = occasionally have it, effect is not severe
- 2 = occasionally have it, effect is severe
- 3 = frequently have it, effect is not severe
- 4= frequently have it, effect is severe
Key to Questionnaire
Optimal Health: less than 10
Mild Toxicity: 10 to 50
Moderate Toxicity: 50 to 100
Severe Toxicity: over 100
Point scale:
Point scale:
Digestive Tract
____ Nausea or vomiting
____ Diarrhea
____ Constipation
____ Bloated Feeling
____ Belching or passing gas
____ Heartburn
____ Intestinal, stomach pain
Total ___________
Ears
____ Itchy ears
____ Earaches, ear infection
____ Drainage from ear
____ Ringing in ears, hearing loss
Total ___________
Emotions
____ Mood swings
____ Anxiety, fear or nervousness
____ Anger, irritability or aggressiveness
____ Depression
Total ___________
Eyes
____ Watery or itchy eyes
____ Swollen, reddened or sticky eyelids
____ Bags or dark circles under eyes
____ Blurred or tunnel vision (does not include near or farsightedness)
Total ___________
Head
____ Headaches
____ Faintness
____ Dizziness
____ Insomnia
Total ___________
Heart
____ Irregular or skipped heartbeat
____ Rapid or pounding heartbeat
____ Chest pain
Total ___________
Joints/Muscles
____ Pain or aches in joints
____ Arthritis
____ Stiffness or limitation of movement
____ Pain or aches in muscles
____ Feeling of weakness or tiredness
Total ___________
Lungs
____ Chest congestion
____ Asthma, bronchitis
____ Shortness of breath
____ Difficulty breathing
Total ___________
Point scale:
Mind
____ Poor memory
____ Confusion, poor comprehension
____ Poor concentration
____ Poor physical coordination
____ Difficulty in making decisions
____ Stuttering or stammering
____ Slurred speech
____ Learning disabilities
Total ___________
Mouth/Throat
____ Chronic coughing
____ Gagging, frequent need to clear throat
____ Sore throat, hoarseness, loss of voice
____ Swollen or discolored tongue, gums or lips
____ Canker sores
Total ___________
Nose
____ Stuffy nose
____ Sinus problems
____ Hay fever
____ Excessive mucus formation
____ Sneezing attacks
Total ___________
Skin
____ Acne
____ Hives, rashes or dry skin
____ Hair loss
____ Flushing or hot flashes
____ Excessive sweating
Total ___________
Weight
____ Binge eating/drinking
____ Craving certain foods
____ Excessive weight
____ Compulsive eating
____ Water retention
____ Underweight
Total ___________
Other
____ Frequent illness
____ Frequent or urgent urination
____ Genital itch or discharge
Total ___________
Grand Total __________
Source: The 10-Day Blood Sugar Solution Detox Diet, Dr. Mark Hyman
Announcement
Our calendar is currently closed for booking appointments. New equipment is being installed on 1/27/26. A second therapist (Sarah Hine) is starting at our location and will begin seeing clients soon after we both learn to use the new equipment. Check back here for updates on when the calendar will be open again for scheduling. Thank you for your patience as we go through this transition!