Toxicity Quiz from The Rain Barrel Effect

Created by Dr. Stephen Cabral

To complete the toxicity questionnaire and find your personal results score, simply fill in the blank with a 0, 1, 2, or 3 depending on your typical symptoms.

0 = Never feel this symptom
1 = Feel this symptom 1-2 times per month
2 = Feel this symptom weekly
3 = Feel this symptom daily

Your Information

Full Name:

Email Address:

Head

Headaches/Migraines:

Dizziness/Faintness:

Neck tension:

Cloudy head:

Sinus

Nasal congestion (stuffy nose):

Allergies (seasonal or daily):

Mucus:

Sneezing:

Nose blowing:

Eyes

Dark circles under eyes:

Bags under eyes:

Itchy eyes:

Discharge or watery eyes:

Blurred vision:

Crusted eyes upon waking:

Ears

Itchy ears:

Discharge or drainage from ears:

Ringing in ears, tinnitus:

Excessive wax build up:

Blocked or muffled hearing:

Teeth

Pain in gums or teeth:

Bleeding gums:

Silver fillings (Score with a 3 if you have any metal fillings):

Metal crowns or Root canals (Score a 3 for crowns or root canals):

Mouth

Canker sores:

Cold sores (herpes virus):

Cracking on lips:

Discolored lips:

White film on lips upon waking or after eating:

Tongue

Red dots on tongue:

Sides of tongue have dents (“scalloping”):

White, yellow, or brown coating on tongue:

Cracks or lines on tongue:

Glands

Swollen lymph nodes (neck, armpits, or groin):

Difficulty swallowing:

Loss of voice:

Swollen ankles or wrists/hands/fingers:

Breathing

Chest tension:

Inability to get enough air in:

Chest congestion:

Chronic cough:

Clear throat a lot:

Voice hoarseness:

Weight

Difficulty losing weight:

Gain weight easily:

Feel swollen or puffy:

Retain water:

Binge or compulsive eating:

Joints/Muscles

Pain in joints:

Muscle stiffness:

Limited range of motion:

Muscle weakness/Loss of strength:

Arthritis:

Skin

Acne:

Hair loss:

Flushing/Hot flashes:

Dry, flaky skin:

Excessive sweating:

Hives or itchiness:

Psoriasis, eczema, ringworm or skin rashes:

Sleep

Inability to fall asleep:

Can't stay asleep/Wake up frequently:

Nightmares:

Heart racing at night:

Night sweats:

Energy

Tired upon waking:

Daytime or afternoon fatigue:

General lack of energy:

Apathy:

Lack of ambition or drive:

Hyperactivity (can't sit still – have to always be doing something):

Restlessness (feel uncomfortable with quiet):

Tap feet or shake leg or hands when seated:

Decreased libido or sexual function:

Digestion

Get tired after meals (especially lunch):

Bloating:

Gas:

Belching/Burping:

Heartburn or indigestion:

Diarrhea:

Constipation:

Stomach or intestinal pain:

Nausea or vomiting:

Stomach sticks out more as day progresses:

Mind

Lack of concentration:

Easily distracted or lose train of thought:

Difficulty making decisions:

Brain fog:

Stuttering or difficulty putting together sentences:

Uncoordinated or drop things:

ADD/ADHD or learning disabilities:

Emotions

Anxiety:

Overwhelm:

Irritability:

Anger or rage:

Dark thoughts:

Sad for no reason:

Mood swings:

Depressed:

High-strung:

Seasonal Affective Disorder (SAD):

Immunity

(Score each question below with 10 points if you answered yes)

Frequent colds (more than 2-3 illnesses a year):

Allergies (environmental or non-fatal food sensitivities):

Pneumonia (Score with a 10 if yes within the last 12 months):

Diagnosed disease (Score with a 10 if you have a diagnosed disease):

Unexplained illness (Score with a 10 for an undiagnosed disease):