Dr.Anca’s Toxicity Self Test

Print the following questionnaire and check mark which symptoms apply to you.

Rate each of the following symptoms based upon your health profile for the past 30 days & write your totals on a piece of paper:

0=NEVER/ALMOST NEVER have the symptom

1=OCCASIONALLY have it, effect NOT SEVERE

3=FREQUENTLY have it, effect is NOT SEVERE

4=FREQUENTLY have it, effect NOT SEVERE

5=FREQUENTLY have it, effect is SEVERE

DIGESTIVE SYSTEM

__Nausea or vomiting

__Diarrhea

__Constipation

__Belching, passing gas

__Bloated feeling

__Heartburn

____TOTAL

EARS

__Itchy ears

__Earaches, ear infections

__Drainage from ears

__Hearing loss

__Ringing in ears

____TOTAL

EMOTIONS

__Mood swings

__Anxiety, fear, nervousness

__Depression

____TOTAL

ENERGY/ACTIVITY

__Fatigue, sluggishness

__Apathy, lethargy

__Hyperactivity

__Restlessness

____TOTAL

EYES

__watery, itchy eyes

__Swollen, reddened, or sticky eyelids

__Dark circles under eyes

__Blurred/tunnel vision

____TOTAL

HEAD

__Headaches

__Faintness

__Dizziness

__Insomnia

____TOTAL

HEART

__Skipped heartbeats

__Rapid heartbeats

__Chest pain

____TOTAL

JOINTS/MUSCLES

__Pain or aches in joints

__Arthritis

__Stiffness, limited movement

__Pain, aches in muscles

__Weakness or tiredness in joints

____TOTAL

LUNGS

__Chest congestion

__Asthma, bronchitis

__Shortness of breath

__Difficulty breathing

____TOTAL

MIND

__Poor memory

__Confusion

__Poor concentration

__Difficulty making decisions

__Stuttering, stammering

__Slurred speech

__Learning disabilities

____TOTAL

MOUTH/THROAT

__Chronic coughing

__Gagging, frequent need to clear throat

__Sore throat, hoarse

__Swollen or discolored tongue, gums, or lips

__Canker sores

____TOTAL