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Neurotoxic Questionnaire

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  • This form takes 5-10 minutes to complete. For your convenience there is an option to 'Save and Return Later' at the bottom of the form if needed.

  • Rate Your Health

  • Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year.

    POINT SCALE:
    0 = Never had symptom, 1 = Occasionally have it, mild effect, 2 = Occasionally have it, severe effect,
    3 = Frequently have it, mild effect, 4 = Frequently have it, severe effect

  • Section 1

  • Not
    Severe
    Very
    Severe

  • Section 2

  • Not
    Severe
    Very
    Severe

  • Section 3

  • Not
    Severe
    Very
    Severe

  • Section 4

  • Not
    Severe
    Very
    Severe


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