ASSESSMENT GUIDELINES CLIENT INTAKE EVALUATION

CONTRINDICATIONS FOR COLON IRRIGATION:
DOES PATIENT HAVE:
congestive heart failure YES / NO | diverticulitis YES / NO | ulcerative colitis YES / NO | Crohn's disease YES / NO | severe or internal hemorrhoids YES / NO | tumors in the rectum or colon YES / NO | intestinal perforation YES / NO | carcinoma of the rectum YES / NO | fissures or fistula YES / NO | severe hemorrhoids YES / NO | abdominal hernia YES / NO | renal insufficiency YES / NO | recent colon or rectal surgery YES / NO | cirrhosis of the liver YES / NO | and first and last trimester of pregnancy YES / NO | ALL CURRENT CONDITIONS SHOULD GIVE RISE TO CONCERN & PATIENT SHOULD HAVE PHYSICIAN APPROVAL TO HAVE COLON IRRIGATION TREATMENT- STANDING ORDERS DO NOT APPLY AND CAN NOT BE USED TO AUTHORIZE COLON IRRIGATION IN THESE INSTANCES

Allergies____________________
Name: ______________________________________ Phone______/______-_____
Street: _____________________________________ City _____________________ State ____ Zip__________
DOB____/____/____ M F General Appearance ___________________ Height__________ Weight_________ B/P: ____/____ Pulse:________ Rate:________ Rhythm:________ Strength:________R: __________ Depth:________ Rhythm:________
Breath Sounds: Clear All 4 Quads Crackles________ Wheezes________ Diminished________ Absent________
Other Observations___________________________________________________
T ______ Pain________ SPO2_______ LPM________ Tetanus_______ Cancer: ____________ HTN________ Hepatitis________ Renal________ Respiratory________ Diabetes________ Stroke________ Muscle/Bone________ Cardiac________ GI________ Seizures________ Mental Health_________
Renal________ Bleeding________ Glaucoma________ IV Access________ Nausea________ Dizziness_______ Vomiting______ Alcohol Use? YES NO How Much?_________ How Long?_________
Tobacco Use? YES NO Packs/Day?________ Do You Live w/Someone Who Smokes? YES NO
Recreational Drug Use? Deny Former Use/Current Use Yes: Describe___________________
Medical Conditions_______________________________________________________
Medications______________________________________________________
Previous Hospitalizations__________________________________________
Surgeries____________________________________________________
Teaching Efforts____________________________________________________
Reassessment: Vitals: Same/Worsening/Improving ___________________________ Why Are You Here?: ______________________________________________
How Did Your Problem Present Itself? _______________________________________
How Is Your General Health?______________________________________________

ANESTHESIA PROBLEMS OR FAMILY HISTORY:__________________________

ALLERGIES
________No Known Allergies
Allergen_______________ Reaction_______________
Allergen_______________ Reaction_______________
Allergen_______________ Reaction_______________

Medications: Prescription/ Nonprescription/ Herbals/ Vitamins
Medication_______________ Dose Frequency________ Last Dose________
Medication_______________ Dose Frequency________ Last Dose________
Medication_______________ Dose Frequency________ Last Dose________

Have You Been Able To Follow Prescribed Medications/Treatments? YES NO Why?_____________________________________________________
Family Physician_____________________________________________
Cardiologist________________________________________________
Diabetologist_______________________________________________

NUTRITIONAL /METABOLIC CARE CONCERNS
1. Typical Daily Food Intake_________________________________________ Fluid Intake___________________
2. Appetite: Good/Fair/Poor If Poor, How Long? ________ Recent Changes In Appetite/Eating Patterns YES NO Details_______________________________________________________________
3. Recent Weight Changes: YES NO Amt/Time________________________________
4. Food Or Eating: Discomfort / Difficulty Swallowing / Difficulty Chewing
Special Diet: YES NO
Details_________________________________________________________
5. Healing: skin lesions heal well YES NO
Details___________________________________________________________
6. Recent Experience With Fever Or Chills? YES NO Details__________________________
7. Method And Frequency Of Blood Sugar Monitoring: Frequency: ______________________
Meter Type: ______________________________
8. Other Observations______________________________________________
Nutrition Needs
Fluid Volume Risk For Deficit / Excess
Altered Nutrition: Obesity(Risk For) / Nut. Deficit / Impaired Swallowing / Risk For Aspiration

ELIMINATION CARE CONCERNS
1. Bladder: No Problems / Urgency / Retention / Dribbling / Frequency / Burning / Incontinence / Hematuria Other___________________________________________________________
2. Bowel: No Problems / Diarrhea / Constipation / Incontinence / Pain / Blood In Stool / Hemorrhoids Other___________________________________________Frequency ____________________ Last Bowel Movement________________________________
Interventions: None / Laxatives / Enemas / Other_______________________________ Frequency________________
3. Other Observations: _____________________________________________
Altered Urinary Elimination YES NO Details______________________________
Altered Bowel Elimination YES NO Details_______________________________

ACTIVITY/EXERCISE CARE CONCERNS
1. Mobility Status: Ambulatory / Ambulatory w/Assist / Transfer w/Assist / Bed Rest
2. Assistive Devices: Cane / Walker / Crutches / Wheelchair / Prosthesis (Type)_________________
Other__________________________ w/Patient YES NO
3. Limitations: None / Weakness / Fatigue / Sob / Dizziness / Syncope / Fainting / Pain Details______________Cough Details _____________________ Other_______________________________
4. Adls: (I=Independent, A=Assist D=Dependent)
___Feeding ___Toileting ___Grooming ___Dressing ___Driving ___Housework ___Cooking
6. Level Of Exercise: Sedentary / Light / Moderate / High Times Per Week_________
8. Other Observations: ____________________________________________________
Impaired Mobility
Fall Risk
Self Care Needs
Activity Intolerance
Ineffective:
Breathing
Pattern
Airway Clearance
Decreased Cardiac Output
Impaired Gas Exchange

SLEEP/REST CARE CONCERNS
1. SLEEP: No Problems / Difficulty Falling Asleep / Not Rested After Sleep Other__________________________
What Helps You Sleep? __________________________________________________________________________
Sleep Routine: Bedtime__________ # Of Hours__________ # Of Pillows__________ Naps___________________
2. Other
Sleep Pattern
Disturbance

COGNITIVE/PERCEPTION CARE CONCERNS
1. Communication/Learning: Primary Language: English / Spanish / Vietnamese / Other______________________
Reading Problems: YES NO :___________________ Recent Memory Changes: YES NO :_____________________
Hearing: No Problems Impaired:___________________________________ Aids - w/Patient? YES NO
Vision: No Problems Impaired: ___________________________ Glasses Contacts - w/Patient? YES NO
Smell: No Problems Impaired:____________________ Taste: No Problems Impaired:___________
Easiest Way To Learn: Read / Demonstrate / Video/TV Pictures / Groups / Individual Instruction
Readiness To Learn/Motivation: Asks Questions Eager To Learn / Anxious / Denies Need For Education
Uncooperative / Unable To
Assess_________________________________________________
2. PAIN/DISCOMFORT: YES NO Details________________________________
Current Pain Level (1-10) _________ Acceptable Level Of Pain: _________ How Is Pain Controlled_____________
Numbness/Tingling: YES NO Details_____________________________________
3. Other Observations:________________________________________________
Impaired Verbal
Communication
Sensory/Perceptual
Alteration
Auditory
Gustatory
Olfactory
Visual
Kinesthetic
Tactile
Pain
Knowledge Deficit Details_________________________________________________

SELF-PERCEPTION/SELF-CONCEPT CARE CONCERNS
1. Expectations Or Concerns Regarding Your Hospitalization? ____________________
2. Is Patient’s Behavior Appropriate To Situation: YES NO Describe________________
3. Other Observations__________________________________________________
Anxiety
Fear
Powerlessness
Hopelessness
Body Image
Disturbance

ROLE/RELATIONSHIPS CARE CONCERNS
1. Who Do You Rely On For Support?____________________________________
2. How Will Your Illness Affect Your Family/Significant Other?__________________
3. Other Observations:________________________________________________
Family Needs
Parenting Needs

SEXUALITY/REPRODUCTION CARE CONCERNS
1. SEXUALITY/REPRODUCTIVE: No Problems Changes/Concerns:_______________________
2. FEMALES: Pregnant YES NO Due Date:___________ Receiving Prenatal Care From:_____________________
3. Last Menses? _____________ Post Menopausal
4. Other Observations: ___________________________________________________
Altered Sexuality
Patterns
Pregnancy
Prenatal Care Needs

COPING/STRESS CARE CONCERNS
1. Has This Illness Caused Stress? YES NO Details_______________________
Do You Feel You Are Dealing Adequately With The Stress? YES NO Details__________
2. Have You Ever Suffered From: Depression Or Emotional Illness: YES NO (Stop Here If No Hx)
Have You Ever Attempted Suicide? YES NO Date:____/____/____
If Yes, Currently Thinking About Hurting Yourself? YES NO
3. Other Observations: Ineffective Coping / Impaired Adjustment / Suicide Risk / Post Trauma Response

Oral Mucosa: Moist Dry Lesions Other___________________
Dentures Upper Full Partial / Lower Full Partial w/Patient YES NO
Skin Condition: Warm / Dry / Pale / Dusky / Cool / Moist
Balance: Steady / Unsteady / Unable To Stand
Gait: Normal / Limps / Shuffles
ROM: Full / Active / Passive / Restricted______________________
Immobile_________________________________________________
Grip Strength: Equal, Strong Weak___________________________
Paralysis_____________________________________________
Foot/Leg Strength: Equal, Strong Weak_______________________
Paralysis____________________________________________
Joint Swelling_____________________________________________
Contractures___________________ Absent Body Part__________
Other Observations_____________________________________________

COGNITIVE/PERCEPTUAL PATTERN
Other Observations:___________________________________________
Verbal Response: Oriented / Confused / Inappropriate / Sounds
Incomprehensible Sounds / Intubated/Trach / None
Motor Response: Follows Instruction/Spontaneous Movement / Withdraws From Touch / Withdraws From Pain Flexes With Pain / Extends With Pain None
Communication: Grasps Ideas And Questions (Abstract, Concrete)
ELIMINATION Aphasia____ Receptive____ Expressive ____ Dysphasia____ Slurred Speech____
Intravenous, Drainage, Suction:
Memory: Observed Short Term Memory Lapses Other_____________________
EYES EARS
Reads Newsprint? YES NO Hears Whispers? YES NO
Other Observations______________________________________________
COPING/ROLE RELATIONSHIP/SELF-CONCEPT_____________________
Abdomen: Soft Firm Tender Hard Distended
Bowel Sounds: Present In All 4 Quadrants None
Other Observations____________________________________________
Emotional Status: Cooperative / Uncooperative / Anxious / Combative / Depressed / Withdrawn / Agitated
Interaction With Family______________________________________
Other Observations__________________________________________

I. CIRCLE APPROPRIATE ANSWER (leave Blank if you do not understand question):
1. YES / NO Is your general health good?
details: __________________________________________________
2. YES / NO Has there been a change in your health within the last year?
details: __________________________________________________
3. YES / NO Have you been hospitalized had a serious illness in the last three years?
details: __________________________________________________
4. YES / NO Are you being treated by a physician now? For what?
Date of last medical exam ____/____/____
details: __________________________________________________
Date of last Dental exam ____/____/____
details: __________________________________________________
5. YES / NO Have you had problems with prior colonic treatments?
details: __________________________________________________
6. YES / NO Are you in pain now?
details: __________________________________________________

II. HAVE YOU EXPERIENCED:
7. YES / NO Chest pain (angina)?
details: __________________________________________________
8. YES / NO Swollen ankles?
details: __________________________________________________
9. YES / NO Shortness of breath?
details: __________________________________________________
10. YES / NO Recent weight loss, fever, night sweats?
details: __________________________________________________
11. YES / NO Persistent cough, coughing up blood?
details: __________________________________________________
12. YES / NO Bleeding problems, bruising easily?
details: __________________________________________________
13. YES / NO Sinus problems?
details: __________________________________________________
14. YES / NO Difficulty swallowing?
details: __________________________________________________
15. YES / NO Diarrhea, constipation, blood in stools?
details: __________________________________________________
16. YES / NO Frequent vomiting, nausea?
details: __________________________________________________
17. YES / NO Difficulty urinating, blood in urine?
details: __________________________________________________
18. YES / NO Dizziness?
details: __________________________________________________
19. YES / NO Ringing in ears?
details: __________________________________________________
20. YES / NO Headaches?
details: __________________________________________________
21. YES / NO Fainting spells?
details: __________________________________________________
22. YES / NO Blurred vision?
details: __________________________________________________
23. YES / NO Seizures?
details: __________________________________________________
24. YES / NO Excessive thirst?
details: __________________________________________________
25. YES / NO Frequent urination?
details: __________________________________________________
26. YES / NO Dry mouth?
details: __________________________________________________
27. YES / NO Jaundice?
details: __________________________________________________
28. YES / NO Joint pain, stiffness?
details: __________________________________________________

III. DO YOU HAVE/HAVE YOU HAD:
29. YES / NO Heart disease?
details: __________________________________________________
30. YES / NO Heart attack, heart defects?
details: __________________________________________________
31. YES / NO Heart murmurs?
details: __________________________________________________
32. YES / NO Rheumatic fever?
details: __________________________________________________
33. YES / NO Stroke, hardening of arteries?
details: __________________________________________________
34. YES / NO High blood pressure?
details: __________________________________________________
35. YES / NO Asthma, TB, emphysema, other lung diseases?
details: __________________________________________________
36. YES / NO Hepatitis, other liver disease?
details: __________________________________________________
37. YES / NO Stomach problems, ulcers?
details: __________________________________________________
38. YES / NO Allergies to: drugs, foods, medications, latex?
details: __________________________________________________
39. YES / NO Family history of diabetes, heart problems, tums?
details: __________________________________________________
40. YES / NO HIV/AIDS
details: __________________________________________________
41. YES / NO Tums, cancer?
details: __________________________________________________
42. YES / NO Arthritis, rheumatism?
details: __________________________________________________
43. YES / NO Eye diseases?
details: __________________________________________________
44. YES / NO Skin diseases?
details: __________________________________________________
45. YES / NO Anemia?
details: __________________________________________________
46. YES / NO VD (syphilis, gonorrhea)?
details: __________________________________________________
47. YES / NO Herpes?
details: __________________________________________________
48. YES / NO Kidney, bladder disease?
details: __________________________________________________
49. YES / NO Thyroid, adrenal disease?
details: __________________________________________________
50. YES / NO Diabetes?
details: __________________________________________________

IV. DO YOU HAVE/HAVE YOU HAD:
51. YES / NO Psychiatric care?
details: __________________________________________________
52. YES / NO Radiation treatments?
details: __________________________________________________
53. YES / NO Chemotherapy?
details: __________________________________________________
54. YES / NO Prosthetic heart valve?
details: __________________________________________________
55. YES / NO Artificial joint?
details: __________________________________________________
56. YES / NO Hospitalization?
details: __________________________________________________
57. YES / NO Blood transfusions?
details: __________________________________________________
58. YES / NO Surgeries?
details: __________________________________________________
59. YES / NO Pacemaker?
details: __________________________________________________
60. YES / NO Contact lenses?
details: __________________________________________________

V. ARE YOU TAKING:
61. YES / NO Recreational drugs?
details: __________________________________________________
62. YES / NO Drugs, medications, over-the-counter medicines
details: __________________________________________________
63. YES / NO Tobacco in any form?
details: __________________________________________________
64. YES / NO Alcohol?
details: __________________________________________________
natural remedies, (including Aspirin)?

VI. WOMEN ONLY:
65. YES / NO Are you could you be pregnant nursing?
details: __________________________________________________
66. YES / NO On any form of birth control?
details: __________________________________________________

VII. ALL PATIENTS:
67. YES / NO Do you have/have you any diseases/medical problems NOT on this form?
details: __________________________________________________
68. YES / NO Headaches of various types
details: __________________________________________________
69. YES / NO Back pain
details: __________________________________________________
70. YES / NO Dementia
details: __________________________________________________
71. YES / NO Depression
details: __________________________________________________
72. YES / NO Forgetfulness
details: __________________________________________________
73. YES / NO Drowsiness
details: __________________________________________________
74. YES / NO Burning sensations in the face, eyes, hands feet
details: __________________________________________________
75. YES / NO Tics (repetitious, sudden, involuntary movements)
details: __________________________________________________
76. YES / NO Lack of ability to concentrate
details: __________________________________________________
77. YES / NO Stup
details: __________________________________________________
78. YES / NO Indecision
details: __________________________________________________
79. YES / NO Bloating
details: __________________________________________________
80. YES / NO Fatigue
details: __________________________________________________
81. YES / NO Dermatological conditions
details: __________________________________________________
82. YES / NO Abdominal pain
details: __________________________________________________
83. YES / NO Dry eyes
details: __________________________________________________
84. YES / NO Tearing eyes
details: __________________________________________________
85. YES / NO Vision disturbances
details: __________________________________________________
86. YES / NO Sinus problems
details: __________________________________________________
87. YES / NO Abdominal cramps
details: __________________________________________________
88. YES / NO Heart arrhythmias (erratic heartbeats)
details: __________________________________________________
89. YES / NO Indigestion
details: __________________________________________________
90. YES / NO Nausea
details: __________________________________________________
91. YES / NO Hemorrhoid pain
details: __________________________________________________
92. YES / NO Bad breath
details: __________________________________________________
93. YES / NO Body odor
details: __________________________________________________
94. YES / NO Foot odor
details: __________________________________________________
95. YES / NO Irritability
details: __________________________________________________
96. YES / NO Constipation
details: __________________________________________________
97. YES / NO Diarrhea
details: __________________________________________________
98. YES / NO Flatulence
details: __________________________________________________
99. YES / NO Cyza (common cold)
details: __________________________________________________
100. YES / NO Catarrh (inflammation of mucous membranes)
details: __________________________________________________
101. YES / NO Insomnia
details: __________________________________________________
102. YES / NO Fitful sleep
details: __________________________________________________
103. YES / NO Prolapse of abdominal gans
details: __________________________________________________
104. YES / NO Arthritis
details: __________________________________________________
105. YES / NO Photophobia
details: __________________________________________________
106. YES / NO Pain behind the eyes
details: __________________________________________________
107. YES / NO Sensitivity to noise
details: __________________________________________________
108. YES / NO Melancholy
details: __________________________________________________
109. YES / NO Insanity
details: __________________________________________________
110. YES / NO Coma
details: __________________________________________________
111. YES / NO Delirium
details: __________________________________________________
112. YES / NO Cataracts
details: __________________________________________________
113. YES / NO Hypertension
details: __________________________________________________
114. YES / NO Hypotension
details: __________________________________________________
115. YES / NO Hardening of the arteries
details: __________________________________________________
116. YES / NO Appendicitis
details: __________________________________________________
117. YES / NO Inflammation enlargement of the spleen
details: __________________________________________________
118. YES / NO Ovarian cysts
details: __________________________________________________
119. YES / NO Tums
details: __________________________________________________
120. YES / NO Muscle atrophy
details: __________________________________________________
121. YES / NO Degeneration of gans
details: __________________________________________________
122. YES / NO Skin wrinkles
details: __________________________________________________
123. YES / NO Complexion alterations
details: __________________________________________________
124. YES / NO Boils
details: __________________________________________________
125. YES / NO Carbuncles
details: __________________________________________________
126. YES / NO Itching acne
details: __________________________________________________
127. YES / NO Posture alterations
details: __________________________________________________
128. YES / NO Clammy skin
details: __________________________________________________
129. YES / NO Fallen arches
details: __________________________________________________
130. YES / NO Fibrocystic breasts
details: __________________________________________________
131. YES / NO Leg pains
details: __________________________________________________
132. YES / NO Malaise
details: __________________________________________________
133. YES / NO Twitching of the muscles
details: __________________________________________________
134. YES / NO Muscle inflammations
details: __________________________________________________
135. YES / NO Degenerate, unclean thoughts
details: __________________________________________________
136. YES / NO Mastitis
details: __________________________________________________
137. YES / NO Kidney disorders
details: __________________________________________________
138. YES / NO Tonsil troubles
details: __________________________________________________
139. YES / NO Bladder infections
details: __________________________________________________
140. YES / NO Bad dreams
details: __________________________________________________

 

TOXICITY QUESTIONNAIRE

For each question, circle either YES or NO.

Select the one choice that most closely represents your individual situation. When you have finished answering all sixty-five questions, ass up the number of circled YES answers.

 

1. YES / NO Do you use plastic containers to store food or drinking water?

2. YES / NO Do you eat microwaved foods that come packaged with plastic
wrap?

3. YES / NO Do you eat non-organic cereals, bread, or other grain products?

4. YES / NO Do you use deodorants, shampoos, and soaps?

5. YES / NO Do you use aftershave, lotions, or perfumes?

6. YES / NO DO you use cosmetics or hair colorings?

7. YES / NO Do you live or work in an area that has synthetic carpeting?

8. YES / NO Do you live or work in an area that has wood cabinets or new
furnishings?

9. YES / NO Do you live or work near agricultural areas?

10. YES / NO Do you live or work in an area that has painted walls or ceilings?

11. YES / NO Do you drink non-organic coffee?

12. YES / NO Do you use sugar substitutes or eat any foods that contain
low-calorie sugar substitutes or sweeteners?

13. YES / NO Do you eat foods that contain hydrogenated fats, such as margarine,
or do you eat any foods that contain canola oil or cottonseed oil?

14. YES / NO Do you eat fat-free foods or snacks made with fat substitutes?

15. YES / NO Do you ever drink tap water at home or at restaurants?

16. YES / NO DO you eat non-organic fruits, vegetables, grains, meats (all types),
or dairy foods (all types)?

17. YES / NO Do you breathe polluted air?

18. YES / NO Do you drive a motor vehicle?

19. YES / NO Do you eat fish?

20. YES / NO Do you wear synthetic clothing or have your clothes dry-cleaned?

21. YES / NO Are you often irritable?

22. YES / NO Are you a smoker?

23. YES / NO Do you have difficulty breathing when anxious?

24. YES / NO Do you sometimes use bug-killers?

25. YES / NO Do you often have a loss of memory and inability to concentrate?

26. YES / NO Do you sometimes feel dizzy?

27. YES / NO DO you sometimes hear ringing or other sound in your ears?

28. YES / NO Do you get skin rashes very easily?

29. YES / NO Do you have frequent urination in the night?

30. YES / NO Is your menstrual cycle often erratic or interrupted?

31. YES / NO Do you have excessive hair loss?

32. YES / NO Do you sometimes have unexplained numbness?

32. YES / NO Do you sometimes have unexplained nauseous?

33. YES / NO Do you often feel very fatigues or nauseous?

34. YES / NO Does your speech sometimes become slurred or disordered?

35. YES / NO Have you received three or more vaccinations?

36. YES / NO Do you belong to one or more of the following groups, as a
professional or hobbyist?

Agricultural product handlers, asbestos abatement technicians, auto mechanics, battery manufacturers, battery recyclers, canning plant workers, carpenters, ceramic manufacturers, construction workers, cooks, cosmetic manufacturers, cosmetologists, dental assistants, dental lab workers, dentists, diesel equipment mechanics, dynamite manufacturers, dynamiters, electronic assembly workers, electronic component manufacturers, electroplaters, engravers, explosives experts, farmers, fertilizer manufacturers, fiberglass installers, fiberglass manufacturers, firemen, firing range operators, fishermen, florescent tube manufacturers, food processors, foundry workers, glass manufacturers, glassblowers, grinder operators, hairdressers, hazardous material workers, ink manufacturers, jewelers, laboratory workers, landfill workers, landscapers, lumber processors, lumber yard workers, metal recyclers, metal sculptors, military soldiers, miners, mail technicians, painters (residential and commercial), paint manufacturers, pharmaceutical workers, photographers, physicians, plastic product, manufacturers, plumbers, plumbing supply manufacturers, policemen, potters, preservative manufacturers, printers, search-and-rescue workers, ship dock workers, smelting plant workers, solderers, tanners, tattoo artists, truck mechanics, waste handlers, well diggers.

37. YES / NO Do you have learning disabilities?

38. YES / NO Do you have headaches?

39. YES / NO Do you stutter or stammer?

40. YES / NO Do you have chronic coughing?

41. YES / NO Do you have heartburn?

42. YES / NO Do you have mood swings?

43. YES / NO Do you have depression?

44. YES / NO Do you have hay fever?

45. YES / NO Do you have insomnia?

46. YES / NO Do you sometimes eat broiled, fried, or barbecued foods?

47. YES / NO Do you eat less than three servings of fruits and vegetables daily?

48. YES / NO Do you eat whole-grain or natural-fiber foods daily?

49. YES / NO Do you rarely drink several glasses of pure water daily?

50. YES / NO Do you eat white flour foods and drink sodas often?

51. YES / NO Do you use home-cleaning products?
52. YES / NO Do you take synthetic vitamins daily or several times a week?

53. YES / NO Do you not exercise daily for thirty minutes or more?

54. YES / NO Are your bowel movements irregular?

55. YES / NO Do you travel in heavy commuter traffic daily?

56. YES / NO Do you eat fast food or frozen food at least twice a week?

57. YES / NO Does your family have a history of cancer, diabetes, heart disease,
obesity or depression?

58. YES / NO Have you had cancer, diabetes, hear disease, depression, obesity,
liver disease or high blood pressure?

59. YES / NO Do you have metal fillings in your teeth, and have you had dental
surgery?

60. YES / NO Are you under significant daily stress?

61. YES / NO Do you use prescription drugs or illegal nonprescription drugs?

62. YES / NO Have you had surgery that used anesthesia?

63. YES / NO Do you have temporal mandibular joint issues?

64. YES / NO Do you often feel bloated?
65. YES / NO Have you had suicidal thoughts?

Number of YES answers _________________

Your total number of YES answers determines your relative toxicity level. (Please note: this is not a scientific test or health evaluation. It simply suggests the possible extent to which you carry a body burden of chemicals.)

1-15 Mildly Toxic
16-28 Generally Toxic
29-45 Very Toxic
46-65 Severely Toxic

As you no doubt noticed, you are toxic even if you answered only a few questions in the affirmative. Toxicity varies only by degree. That reality generally reflects the findings from widespread blood tests conducted by the U.S. Centers for Disease Control and Prevention.

 

 

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