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CHECKLIST FOR TOXIN EXPOSURE

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CHECKLIST FOR TOXIN EXPOSURE*

This is a guide to determine if you are at risk of having environmental toxins in your body. Most healthy people's systems are able to remove most environmental toxins from the body. Too much exposure, or the body's systems not functioning properly, can contribute to a build-up of toxins in the body. This is a checklist to help you evaluate potential risks and provide information to share with your physician. This is not intended to substitute for proper medical testing. It is simply a checklist to give to a competent medical professional.

Medical Symptoms Score (0-5) (0 = not an issue, 5 = severe problem)

1. Headaches
0 1 2 3 4 5

2.

Allergies

 

0 1 2 3 4 5

3.

Insomnia

 

0 1 2 3 4 5

4.

Cough or Mucus

 

0 1 2 3 4 5

5.

Skin Rashes

 

0 1 2 3 4 5

6.

Fatigue

 

0 1 2 3 4 5
7. Memory Loss

 

0 1 2 3 4 5

8.

Kidney or Liver Problems

 

0 1 2 3 4 5

9.

Joint Pains

 

0 1 2 3 4 5

10.

Weakened Immune System

 

0 1 2 3 4 5
11. Lack of Energy

 

0 1 2 3 4 5

12.

Vision Loss

 

0 1 2 3 4 5
13. Nausea

 

0 1 2 3 4 5

14.

Mild Depression

 

0 1 2 3 4 5
15. Confusion

 

0 1 2 3 4 5

16.

Anxiety

 

0 1 2 3 4 5
17. Cannot Lose Weight

 

0 1 2 3 4 5

18.

Muscle Twitches

 

0 1 2 3 4 5

19.

Poor Balance

 

0 1 2 3 4 5
20. Dizziness

 

0 1 2 3 4 5

TOTAL (Health Category)

 


(This is the most important category, if your score is above 65 you should seek medical advice and testing.)

Foods Score (0-5) (0 = low consumption, 5 = frequent consumption)

1. Dairy Products

 

0 1 2 3 4 5
2. Highly Processed Foods

 

0 1 2 3 4 5
3. Non-Organic Fruits

 

0 1 2 3 4 5
4. Fish

 

0 1 2 3 4 5
5. Beef

 

0 1 2 3 4 5
6. Smoked Meats

 

0 1 2 3 4 5
7. Non-Organic Food

 

0 1 2 3 4 5
8. Soda

 

0 1 2 3 4 5
9. Restaurant Eating

 

0 1 2 3 4 5

TOTAL (Food Category)

 

Medication and Substances  (0-5) (0 = low consumption, 5 = frequent consumption)

1. Sugar

 

0 1 2 3 4 5
2. Nicotine

 

0 1 2 3 4 5

3.

Alcohol

 

0 1 2 3 4 5
4. Caffeine

 

0 1 2 3 4 5

5.

Chemicals

 

0 1 2 3 4 5

6.

Prescription Meds

 

0 1 2 3 4 5
7. Over-the-Counter Meds

 

0 1 2 3 4 5
8. Recreational Drugs

 

0 1 2 3 4 5
9. Artificial Sweeteners

 

0 1 2 3 4 5

TOTAL (Medication & Substances Category)

 

Other Factors Score (0 or 5) (0=No, 5=Yes)

1. Live Near Waste Site

 

0 1 2 3 4 5
2. Live Near Power Plant

 

0 1 2 3 4 5
3. Auto Mechanic Plumber Construction

 

0 1 2 3 4 5
4. Work with Paints and Dyes

 

0 1 2 3 4 5
5. Stressful Relationships

 

0 1 2 3 4 5

6.

Stressful Work

 

0 1 2 3 4 5
7. Chemical Deodorants

 

0 1 2 3 4 5
8. Use Chemical Cleaners at Home

 

0 1 2 3 4 5
9. Exposed to Chemicals at Work

 

0 1 2 3 4 5
10. Drink Well Water

 

0 1 2 3 4 5
11. Swim in Ponds and Lakes

 

0 1 2 3 4 5
12. Have Dental Amalgams

 

0 1 2 3 4 5
13. Household Mold

 

0 1 2 3 4 5
14. Long Time Driving in Car

 

0 1 2 3 4 5
15. Homes with Flaking Paint

 

0 1 2 3 4 5

16.

Live Near Strip Mine or Gas Well

 

0 1 2 3 4 5
17. Live Farm or Sprayed Fields

 

0 1 2 3 4 5
18. Work Around Petroleum Products

 

0 1 2 3 4 5

TOTAL (Other Category)

 


(This is an important category. Scores above 58 are of concern and testing is recommended.)

 

TOTAL SCORE :

TOTAL SCORE = TOTAL (Health Category) + TOTAL (Food Category) + TOTAL (Medication & Substances Category) + TOTAL (Other Category)

Scores 100 and below have low risk of environmental toxins in the body.

Scores 100 to 139 have moderate risk of environmental toxins in the body.

Scores of 130 to 169 have high risk of environmental toxins in the body.

Scores of 170 and above have very high risk of environmental toxins in the body.

*This checklist is not approved by the FDA. It is not intended to treat, diagnose, or mitigate any disease or physical condition.