First Name
*
Last Name
*
Phone
*
Email
*
Health data consent
*
I understand this assessment collects information about my symptoms and health, and I consent to Holistic Magazine collecting and storing this information.
Privacy Policy
Headaches or migraines
*
Never
1-2 times per month
Weekly
Daily
Brain fog or cloudy head
*
Never
1-2 times per month
Weekly
Daily
Nasal congestion, mucus, or frequent nose blowing
*
Never
1-2 times per month
Weekly
Daily
Sneezing, itchy eyes, or watery eyes
*
Never
1-2 times per month
Weekly
Daily
Dark circles or bags under eyes
*
Never
1-2 times per month
Weekly
Daily
Ringing in ears, itchy ears, or ear drainage
*
Never
1-2 times per month
Weekly
Daily
White, yellow, or brown coating on tongue
*
Never
1-2 times per month
Weekly
Daily
Canker sores or cold sores
*
Never
1-2 times per month
Weekly
Daily
Sore, painful, or bleeding gums
*
Never
1-2 times per month
Weekly
Daily
How many silver fillings, metal crowns, or root canals do you have?
*
None
1
2
3 or more
How difficult is it for you to lose weight?
*
Not difficult
Somewhat difficult
Difficult
Very difficult
Feeling puffy, swollen, or retaining water
*
Never
1-2 times per month
Weekly
Daily
Joint pain, muscle stiffness, or arthritis
*
Never
1-2 times per month
Weekly
Daily
Swollen lymph nodes or sore glands
*
Never
1-2 times per month
Weekly
Daily
Chest congestion, chronic cough, or frequent throat clearing
*
Never
1-2 times per month
Weekly
Daily
Shortness of breath or chest tightness
*
Never
1-2 times per month
Weekly
Daily
Acne or breakouts
*
Never
1-2 times per month
Weekly
Daily
Itchy skin, hives, rashes, eczema, or psoriasis
*
Never
1-2 times per month
Weekly
Daily
Excessive sweating, night sweats, or hot flashes
*
Never
1-2 times per month
Weekly
Daily
Trouble falling or staying asleep, or a racing heart at night
*
Never
1-2 times per month
Weekly
Daily
Waking up tired
*
Never
1-2 times per month
Weekly
Daily
Afternoon fatigue or general lack of energy
*
Never
1-2 times per month
Weekly
Daily
Feeling tired after meals
*
Never
1-2 times per month
Weekly
Daily
Low drive, motivation, or libido
*
Never
1-2 times per month
Weekly
Daily
Bloating, gas, or a belly that expands as the day goes on
*
Never
1-2 times per month
Weekly
Daily
Heartburn, indigestion, or belching
*
Never
1-2 times per month
Weekly
Daily
Constipation
*
Never
1-2 times per month
Weekly
Daily
Diarrhea or loose stools
*
Never
1-2 times per month
Weekly
Daily
Stomach pain or nausea
*
Never
1-2 times per month
Weekly
Daily
Trouble concentrating or easily distracted
*
Never
1-2 times per month
Weekly
Daily
Anxiety or feeling overwhelmed
*
Never
1-2 times per month
Weekly
Daily
Irritability, anger, or mood swings
*
Never
1-2 times per month
Weekly
Daily
Low mood or feeling sad for no reason
*
Never
1-2 times per month
Weekly
Daily
More than 2-3 colds or infections in a year
*
No
Yes
Pneumonia or an unexplained illness
*
No
Yes
A diagnosed chronic disease
*
No
Yes
TQ Head Score
TQ Mouth Score
TQ Body Score
TQ Skin Score
TQ Sleep Score
TQ Digestion Score
TQ Mind Score
TQ Immune Score
Toxicity Quiz Score