Toxicity Assessment Form

Please fill out this form and click “Submit” at the bottom. Thank you!

If you have any questions, don’t hesitate to ask.

Your Study Participant Number:(required)

Date:(required)

Please answer the following questions related to your lifestyle and habits that may contribute to overall toxicity.

Do you smoke or use tobacco?(required) Yes

How many per day? If none, put 0(required)

Do you drink coffee or caffeinated beverages or energy drinks(required) Yes

How many per day? If none, put 0(required)

Do you drink tap water?(required) Yes

Do you use plastic in the microwave for cooking?(required) Yes

Do you use cosmetics, soaps, lotions, shampoos, or deodorants with ingredients that are difficult to pronounce?(required) Yes

Do you eat commercially grown food (non-organic)?(required) Yes

Do you eat pre-packaged or boxed food products?(required) Yes

Do you use a cell phone or computer?(required) Yes

How many hours per day?(required)

Please rate the next questions on a scale of 1 to 10. With 10 being severe/chronic problems.

Joint Pain(required) 1

Stress(required) 1

Problems Sleeping(required) 1

Fatigue(required) 1

Foggy Brain(required) 1

Memory Problems(required) 1

Difficulty Focusing(required) 1

Blurred Vision(required) 1

Gout(required) 1

Acid Reflux(required) 1

Inflammation(required) 1

Diarrhea(required) 1

Anxiety(required) 1

Numbness(required) 1

Poor Circulation(required) 1

Body Odor(required) 1

Stinky Feet(required) 1

Liver Spots(required) 1

Acne/Skin Blemishes(required) 1

Congestion(required) 1

Thank you so much for your time and participation in this study.

* This Site Does Not Provide Medical Advice *