Toxicity Questionnaire

The Toxicity Questionnaire is designed to aid in assessing your potential need for a detox program.

COMPLETE OUR TOXICITY QUESTIONNAIRE

First Name

Last Name

Phone Number

Section I: Symptons

Rate each of the following based upon your health profile for the past 90 days.

Points	Symptons
0	Rarely or Never Experience the Symptom
1	Occasionally Experience the Symptom, Effect is Not Severe
2	Occasionally Experience the Symptom, Effect is Severe
3	Frequently Experience the Symptom, Effect is Not Severe
4	Frequently Experience the Symptom, Effect is Severe

DIGESTIVE

EARS

EMOTIONS

ENERGY / ACTIVITY

EYES

HEAD

LUNGS

MIND

MOUTH/THROAT

NOSE

SKIN

HEART

JOINTS / MUSCLES

WEIGHT

OTHER

Section II: Risk of Exposure

Rate each of the following situations based upon your environmental profile for the past 120 days.

0 - Never
1 - Rarely
2 - Monthly
3 - Weekly
4 - Daily

How often are strong chemicals used in your home? (i.e. disinfectants, bleaches, oven/drain cleaners, furniture polish, floor wax, window cleaners, all household cleaners)

How often are you exposed to dust, overstuffed furniture/lint, tobacco smoke, mothballs, incense, or varnish in your home/office/workplace

Rate each of the following situations based upon your environmental profile for the past 120 days.

0 - No
1 - Mild Change
2 - Moderate Change
3 - Drastic Change

Answer yes or no

Do you have a water purification system in your home?

Yes No

Do you have any indoor pets?

Yes No

Do you have an air purification system in your home?

Yes No

Are you a dentist, painter, farm worker or construction worker?

Yes No

Ready to Change Your Life?

Balancing the body for a healthier you!

Jan Kaufman

Certified AEDT Technician

Advanced Energetic Data-field Testing – measures the resistance to the flow of electrons through the body. The purpose is to detect energy imbalances along invisible lines of the body described by acupuncturists as meridians. A dynamic assessment of the meridians of the body’s organs, systems, and tissues, showing much about their basic functional status.

These statements have not been evaluated by the FDA and are not intended to diagnose, treat, cure, mitigate or prevent any disease or illness. No action should be taken solely on this content; regardless of the perceived scientific merit, instead recipients should consult medical professionals on any matter related to their health.