How Toxic Are You? - Kremer Family Chiropractic

Neurotoxic Questionaire
Name
Date
MM slash DD slash YYYY
Address
Address City State / Province / Region ZIP / Postal Code
Home Phone
Mobile
Work
Email Address
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Age
Height
Weight
Status:
- Married
- Separated
- Divorced
- Widowed
- Single
- Partnership
Live with:
- Spouse
- Partner
- Parents
- Children
- Friends
- Alone
Education
Occupation
Hours Per Week
Retired
- Retired
Emergency Contact
Name
Relationship
Address
Phone
How did you hear about our wellness program?
Copyright 2020 Revelation Health, LLC. All Rights Reserved.

What is your major complaint? Please list when each symptom began and be as descriptive as possible.
What medications do you currently take?
What vitamins and/or supplements do you currently take?
Please list your current and past health conditions (such as Diabetes, Mellitus etc).
Is there anything else in your medical history you consider to be relevant (even from childhood)?
Copyright 2020 Revelation Health, LLC. All Rights Reserved.

What is your employment history? Please provide a brief summary with dates if possible.
Please list your past and present hobbies that could be sources of toxicity or chemicals.
How often do you engage in these hobbies currently?
Please list past or present allergies, including allergies to medications.
Please list all past surgeries and the condition that prompted each surgery, including dates.
Please explain your housing history (type of homes, where and when).

Rate each of the following symptoms to the best of your ability based on your typical health profile over the last year. If you cannot answer a question, simply leave it blank.
Point Scale
Anxiety
Please enter a number from 0 to 4.
Sensitivity to light
Please enter a number from 0 to 4.
Mood Swings
Please enter a number from 0 to 4.
Fatigue after exercising (feeling worse)
Please enter a number from 0 to 4.
Enraged behavior or anger for no reason
Please enter a number from 0 to 4.
Bad night vision or seeing halos around lights
Please enter a number from 0 to 4.
Excessive shyness, timidity, social phobia (not typical to your personality)
Please enter a number from 0 to 4.
Shortness of breath, with very little effort
Please enter a number from 0 to 4.
Irritability (not typical to your personality)
Please enter a number from 0 to 4.
Excessive thirst and/or frequent urination
Please enter a number from 0 to 4.
Low body temperature (below 97.5°)
Please enter a number from 0 to 4.
Red eyes or tearing
Please enter a number from 0 to 4.
Insomnia (can’t fall asleep or stay asleep)
Please enter a number from 0 to 4.
Blurred vision at times
Please enter a number from 0 to 4.
Dizziness
Please enter a number from 0 to 4.
Morning stiffness
Please enter a number from 0 to 4.
Sound in ears (ringing or hearing heart beat)
Please enter a number from 0 to 4.
Sensitivity to smells, such as petrochemicals, perfumes, air fresheners
Please enter a number from 0 to 4.
Psychological symptoms, thoughts of suicide
Please enter a number from 0 to 4.
Sensitivity to sound
Please enter a number from 0 to 4.
Chronic fatigue or weakness
Please enter a number from 0 to 4.
Indecisiveness
Please enter a number from 0 to 4.
Non-restful sleep
Please enter a number from 0 to 4.
Feeling of being overwhelmed or fearful
Please enter a number from 0 to 4.
Metallic taste in your mouth
Please enter a number from 0 to 4.
Receive static shock often and more intensely than normal (doorknobs, cars, etc.)
Please enter a number from 0 to 4.
Bad breath
Please enter a number from 0 to 4.
Trouble processing new information
Please enter a number from 0 to 4.
Bleeding gums
Please enter a number from 0 to 4.
Word reversal or trouble finding words
Please enter a number from 0 to 4.
Sensitive teeth
Please enter a number from 0 to 4.
Sensitivity to touch
Please enter a number from 0 to 4.
Canker sores or other sores in the mouth
Please enter a number from 0 to 4.
Short-term memory loss
Please enter a number from 0 to 4.
Floaters, shadows or swimmers when reading or looking at the sky
Please enter a number from 0 to 4.
Chronic sinus congestion
Please enter a number from 0 to 4.
Dry non-productive cough
Please enter a number from 0 to 4.
Swelling eyelids
Please enter a number from 0 to 4.
Peeling on top layer of skin (hands, feet)
Please enter a number from 0 to 4.
Joint pain-not neccesarily true arthritis-can move from joint to joint
Please enter a number from 0 to 4.
Dry skin
Please enter a number from 0 to 4.
Difficulty losing weight regardless of diet or exercise
Please enter a number from 0 to 4.
Heart pain (angina) if you are under 45 years old
Please enter a number from 0 to 4.
Depression
Please enter a number from 0 to 4.
Gout (arthritic pain, especially in big toes)
Please enter a number from 0 to 4.
Persistent fungal or viral infection, including Athlete’s Foot, Warts, Jock Itch or Candidiasis
Please enter a number from 0 to 4.
Pain in shoulders or upper back
Please enter a number from 0 to 4.
Numbness or weakness in arms and legs
Please enter a number from 0 to 4.
Twitching eyelids
Please enter a number from 0 to 4.
Headaches
Please enter a number from 0 to 4.
Anemia (low iron/hemoglobin on blood test)
Please enter a number from 0 to 4.
Wrist/ankle drop or weak extensor muscles
Please enter a number from 0 to 4.
Trouble adding or dividing numbers in your head
Please enter a number from 0 to 4.
Hair falls out (not normal male pattern baldness)
Please enter a number from 0 to 4.
Fluctuating constipation and diarrhea
Please enter a number from 0 to 4.
Stomach pain for no apparent reason
Please enter a number from 0 to 4.
Appetite swings
Please enter a number from 0 to 4.
Rashes or Rosacea
Please enter a number from 0 to 4.
Frequent muscle aches, cramps, unusual sharp, sudden pains
Please enter a number from 0 to 4.
Frequent or prolonged illness or sick days
Please enter a number from 0 to 4.
Cold extremities (hands and feet)
Please enter a number from 0 to 4.
Muscle Twitching
Please enter a number from 0 to 4.
Excessive Sweating, especially at night
Please enter a number from 0 to 4.
Total columns 1&2

Neurotoxic Questionaire

Step 1 of 8

Neurotoxic Questionaire

Emergency Contact

Mercury

Lead

General Toxicity

Mold

Lyme Disease

Health History

Microbiome Health

Point Scale