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Dental Care & Wellness of Sonoma County

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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
Itchy Ears Hissing in Ears
Earaches, Ear Infection Hearing Problems
Drainage from Ears Ringing in Ears
Noise in Ears
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
Watery or Itchy Swollen, Red or Sticky
Bags/Dark Circle Under
Blurred or Tunnel Vision (Does not include near or far sightedness) Eyes
Headaches Faintness
Dizziness Insomnia
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
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
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
Stuffy Nose Bloody Nose
Sinus Problems Hay Fever
Sneezing Attacks Loss of Smell
Excessive Mucus Formation Dry, Crusty Membranes
Unexplained Rashes Excessive Itching
Red Flushed of Color Rough Skin
Acne, Pimples Hives
Hair Loss
Binge Eating, Drinking Craving Certain Foods
Excessive Weight Compulsive Eating
Water Retention Underweight
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
Leukemia Hodgkin's
Any Other:


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