Toxicity Questionnaire

Learn more about services at Dynamic Health Carolinas

Renewal Therapy Pain Management

Rate the following on a 0-4 scale, then use the toxicity score to determine your potential toxicity level.

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    1) Fatigue, low energy, loss of energy?

    01234

    2) Weight loss resistance or sudden weight gain?

    01234

    3) Sleep and/or anxiety issues?

    01234

    4) Joint and muscle aches?

    01234

    5) Short term memory loss, mental fatigue or brain fog?

    01234

    6) Irritability and mood changes?

    01234

    7) Persistent headaches or migraines?

    01234

    8) Digestive issues: heart burn, constipation, diarrhea, bloating?

    01234

    9) Hair thinning and/or hair loss?

    01234

    10) Chronic cold hands or feet?

    01234

    11) Allergies and/or food allergies?

    01234

    12) Eye and/or muscle twitching?

    01234

    13) Acne or skin rashes?

    01234

    14) Dizziness or faintness?

    01234

    15) Sensitivity to smells, including chemicals and perfumes?

    01234
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Learn more about services at Dynamic Health Carolinas

Renewal Therapy Pain Management