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Toxicity Questionnaire

Before you begin: This questionnaire is for informational purposes only and is not a medical diagnosis. Your responses will help Dr. Shelley determine whether the 21-Day Purification Program is right for you.

Please tell us a little bit about yourself

How did you hear about the 21-Day Purification Program and Complete Wellness?

Section I: Symptoms

Rate each of the following based on your health profile for the past 90 days.

0 = Rarely or never experience the symptom 1 = Occasionally experience the symptom, effect is not severe 2 = Occasionally experience the symptom, effect is severe 3 = Frequently experience the symptom, effect is not severe 4 = Frequently experience the symptom, effect is severe

DIGESTIVE

EARS

EMOTIONS

ENERGY/ACTIVITY

EYES

HEAD

LUNGS

MIND

MOUTH/THROAT

NOSE

SKIN

HEART

JOINTS/MUSCLES

WEIGHT

OTHER

SECTION II: Risk of Exposure

Rate each of the following based upon your environmental profile for the past 120 days.

0 = Never

1 = Rarely

2 = Monthly

3 = Weekly

4 = Daily

ENVIRONMENTAL EXPOSURES

HAVE YOU NOTICED HEALTH CHANGES?

0 = No

1 = Mild Change

2 = Moderate Change

3 = Drastic Change

RISK FACTORS

Do you have a water purification system in your home?

Yes

Do you have an air purification system in your home?

Yes

Do you have indoor pets?

Yes

Are you a dentist, painter, farm worker, or construction worker?

Yes

By submitting, you'll be added to our Wellness Series list — unsubscribe anytime.

	0	1	2	3	4
Nausea and/or vomiting
Diarrhea
Constipation
Bloated Feeling
Belching and/or gas
Heartburn

	0	1	2	3	4
Itchy Ears
Earaches or ear infections
Drainage from ears
Ringing in ears or hearing loss

	0	1	2	3	4
Mood swings
Anxiety, fear, or nervousness
Anger, irritability
Depression
Sense of despair
Uncaring or disinterested

	0	1	2	3	4
Fatigue or sluggishness
Hyperactivity
Restlessness
Insomnia
Startled awake at night

	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened, or sticky eyelids
Dark circles under eyes
Blurred or tunnel vision

	0	1	2	3	4
Chest congestion
Asthma or bronchitis
Shortness of breath
Difficulty breathing

	0	1	2	3	4
Poor memory
Confusion
Poor concentration
Poor coordination
Difficulty making decisions
Stuttering, stammering
Slurred speech
Learning disabilities

	0	1	2	3	4
Chronic coughing
Gagging or frequent need to clear throat
Swollen or discolored tongue, gums, lips
Canker sores

	0	1	2	3	4
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucous

	0	1	2	3	4
Acne
Hives, rashes, or dry skin
Hair loss
Flushing
Excessive sweating

	0	1	2	3	4
Pain or aches in joints
Stiffness or limited movement
Pain or aches in muscles
Recurrent back aches
Feeling of weakness or tiredness

	0	1	2	3	4
Binge eating or drinking
Craving certain foods
Excessive weight
Compulsive eating
Water retention
Underweight

	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Leaky bladder
Genital itch, discharge

	0	1	2	3	4
Strong chemicals in home
Pesticides in home
Home treated for insects
Dust, smoke, fumes in home/office
Nail polish, perfume, cosmetics
Diesel, exhaust, gasoline fumes
Nonorganic foods

	0	1	2	3
Health change since moving into your home or apartment
Health change since starting your new job

	0	1	2	3	4
Headaches
Faintness
Dizziness
Pressure

	0	1	2	3	4
Skipped heartbeats
Rapid heartbeats
Chest pain