Neurotoxin Questionnaire (Autonomic Nervous System)

The following is a dys-autonomia questionnaire approved for use in an FDA study on mercury toxicity developed by Dr. Dietrich Klinghardt and Dr. Paula Bickel. You will notice the wide range of symptoms and organs that can be affected by heavy metal toxicity, toxic chemicals, chronic infections and anything else that affects the functional nervous system (ANS).

Rate each on the following symptoms based upon your health profile for the past 30 days.

Point Scale -

	0 - Never or almost never have the symptom
	1 - Occasionally have it, effect is not severe
	2 - Occasionally have it, effect is severe
	3 - Frequently have it, effect is not severe
	4 - Frequently have it, effect is severe

Digestive Tract:

	Nausea or Vomiting		Heartburn
	Diarrhea		Colitis
	Constipation		Abdominal Pain
	Bloated Feeling		Blood in Stool
	Belching, Passing Gas		Ulcer
	Crohn's disease		Poor appetite
	Graves Disease

Ears:

	Itchy Ears		Hissing in Ears
	Earaches, Ear Infection		Hearing Problems
	Drainage from Ears		Ringing in Ears
	Noise in Ears

Emotions:

	Mood Swings		Anger
	Depression		Divorced
	Suicidal Tendencies		Irritability, Aggressiveness
	Anxiety, Fear or Nervousness

Energy Activity:

	Fatigue, Sluggishness		Apathy, Lethargy
	Hyperactivity		Restlessness
	Tire Easily		Tired When Awaken In AM

Eyes:

	Watery or Itchy		Swollen, Red or Sticky
	Bags/Dark Circle Under
	Blurred or Tunnel Vision (Does not include near or far sightedness) Eyes

Head:

	Headaches		Faintness
	Dizziness		Insomnia

Heart:

	Heart Attack		Heart, Chest Pain
	Heart Murmur		Partial Heart Block
	Endocarditis		Angina
	High Blood Pressure		Low Blood Pressure
	Abnormal EKG		Tachycardia (racing heart)

Joints / Muscles:

	Pain or Aches in Joint		Arthritis
	Pain/Aches in Muscles		Feeling or Weakness/Tiredness
	Osteoporosis		Cramp in Leg
	Stiffness, Limitation of Movement

Lungs:

	Chest Congestion		Shortness of Breath
	Asthma		Difficulty Breathing
	Laryngitis 1 or More times per year		Pneumonia 1 or More times per year
	Bronchitis 1 or More times per year

Mind:

	Poor Memory		Poor Concentration
	Learning Disabilities		Stuttering or Stammering
	Slurred Speech		Difficulty Making Decisions
	Confusion, Poor Comprehension		Poor Physical Coordination
	Brain Fog, Hard to Mentally Function

Mouth / Throat:

	Metal Taste in Mouth		Increased Saliva
	Decreased Saliva		Sore Throat
	Chronic Coughing		Loss of Voice
	Canker Sores		Hoarseness
	Bleeding Gums		Gagging, Frequent Need to Clear Throat
	Loosening of Teeth Periodontal Disease
	Swollen or Discolored Tongue, Gums of Lips

Nose:

	Stuffy Nose		Bloody Nose
	Sinus Problems		Hay Fever
	Sneezing Attacks		Loss of Smell
	Excessive Mucus Formation		Dry, Crusty Membranes

Skin:

	Unexplained Rashes		Excessive Itching
	Red Flushed of Color		Rough Skin
	Acne, Pimples		Hives
	Hair Loss

Weight:

	Binge Eating, Drinking		Craving Certain Foods
	Excessive Weight		Compulsive Eating
	Water Retention		Underweight

Endocrine:

	Thyroid Under Over Active		Cold Hands or Feet
	Diabetes		Low Female Hormones
	Estrogen Dominant		Prostrate Problems
	Chronically Sub-Normal Temperatures		Pancreas, Blood Sugar Low or Pancreatitis
	Menstruation, Painful Too Often, Too Seldom

Immune System:

	Autoimmune		Allergies
	Low Immune System		Shingles (Herpes Zoster)
	Chronic Parasites
	Chronic Virus (Herpes I, II, VI, VII, Cytomegalio, Estein Bar)
	Chronic Infections (Lyme, Bartonella, Ehrilcha, Chlamydia, Candida, Babesia, Rickettsia, Mycomplasma, Staph, Strept, Mycobacterium)

Nervous and Neurodegenerative Disorders:

	Multiple Sclerosis		Bells Palsy
	Alzheimer's		Parkinson's
	Knees or Leg Jerk		Epilepsy or Convulsions
	Numbness in Any Part of Body		Tingling in Any Part of Body
	Burning Pain		Tremor of Hands, Feet of Head
	Twitching or Face or Other Muscles

Cancer:

Leukemia

Hodgkin's

Any Other:

TOTAL SCORE:

*Signature:		Date:
(Your digital signature (full name) is as legally binding as a physical signature.)