1.
Do you brush your teeth daily with toothpaste containing fluoride?
Yes No
2.
Do you have "silver" dental fillings?
Yes No
3.
Have you ever had tooth extractions and/or root canal fillings?
Yes No
4.
Do you use unfiltered tap water to brush your teeth, shower, bathe, make coffee or drink?
Yes No
5.
Do you drink bottled water?
Yes No
6.
Do you eat commercial (non-organic) vegetables, fruits, or meat?
Yes No
7.
Do you eat processed food or fast food?
Yes No
8.
Do you eat food that is not certified 100% organic?
Yes No
9.
Do you use artificial sweeteners such as Nutrasweet or Splenda?
Yes No
10.
Do you drink diet sodas several times a week?
Yes No
11.
Do you drink alcoholic beverages regularly?
Yes No
12.
Do you eat fish more than twice a week?
Yes No
13.
Do you drink non-organic coffee?
Yes No
14.
Have you ever smoked or been exposed to second-hand smoke?
Yes No
15.
Do you eat in restaurants more than twice weekly?
Yes No
16.
Have you ever taken antibiotics in your life?
Yes No
17.
Have you ever received a vaccine?
Yes No
18.
Have you ever taken prescription medications or over-the-counter medications, including hormone replacement therapy or birth control?
Yes No
19.
Do you use commercial household cleaners, cosmetics or antiperspirants?
Yes No
20.
Do you have wall-to-wall carpet in your home or office?
Yes No
21.
Have you ever used plastic containers to heat food in the microwave?
Yes No
22.
Do you use non stick pans to cook with?
Yes No
23.
Do you use a wireless telephone inside your house?
Yes No
24.
Do you use bug spray in your home or have a pest control service?
Yes No
25.
Do you use weed killer on your lawn?
Yes No
26.
26. Do you dye or bleach your hair?
Yes No
27.
Do you use cologne or perfume?
Yes No
28.
Do you use make up or cosmetics, moisturizers or body lotion?
Yes No
29.
Do you wear clothes that have been dry-cleaned?
Yes No
30.
Do you wear synthetic materials (such as polyester)?
Yes No
31.
you use a cell phone without any electromagnetic chaos protection?
Yes No
32.
Do you use a laptop computer with a wireless device?
Yes No
33.
Does your occupation expose you to toxins?
Yes No
34.
Do you live in a major metropolitan area?
Yes No
35.
Do you drive in heavy traffic?
Yes No
36.
Do you live near an airport?
Yes No
37.
Do you live within 100 miles of an agricultural area where produce is being grown?
Yes No
38.
Do you work in an environment using fluorescent lighting?
Yes No
39.
Do you regularly swim in a pool or lake?
Yes No
40.
Are you overweight, underweight, or do you have cellulite deposits?
Yes No
41.
Do you gain weight easily?
Yes No
42.
Do you have food cravings, especially carbohydrate-rich foods and/or sweets?
Yes No
43.
Do you have pain or discomfort on the right side of your stomach occasionally or after eating?
Yes No
44.
Are you constipated or do you have less than one bowel movement per day?
Yes No
45.
Do you feel tired, lethargic, or sluggish upon waking and even throughout the day?
Yes No
46.
Do you have trouble sleeping or feel unrefreshed upon waking?
Yes No
47.
Do you have difficulty concentrating or have slow or surreal thinking?
Yes No
48.
Do you have dark circles?
Yes No
49.
Do you feel depressed or have mood changes?
Yes No
50.
Do you often feel stressed or anxious?
Yes No
51.
Do you get more than one or two colds per year?
Yes No
52.
Do you get postnasal drip, congestion, or a stuffy nose or sinuses upon waking or throughout the day?
Yes No
53.
Do you have bad breath, a coated tongue, or a bitter or metallic taste in your mouth?
Yes No
54.
Do you have strong body odor?
Yes No
55.
Do you have strong-smelling urine?
Yes No
56.
Are your nails weak, soft, or brittle?
Yes No
57.
Do you have allergies to various household products, dust, and molds?
Yes No
58.
Do you have eczema, dry skin, acne, or rashes?
Yes No
Do you have any of the following symptoms:
59.
Sensitivity to perfume or other chemical odors
Yes No
60.
Persistent joint and/or muscle pain
Yes No
61.
Chronic infections
Yes No
62.
Depression
Yes No
63.
Fatigue
Yes No
64.
Headaches
Yes No
