Neurotoxic Questionnaire (NTQ) Neurotoxic Questionnaire (NTQ) Step 1 of 2 50% Name of Practitioner (if applicable)(Required) First Last Practitioner/Office Email (if applicable)(Required) Today's Date(Required) MM slash DD slash YYYY Your Name(Required) First Last Your Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Your Phone(Required)Your Email(Required) Current Age(Required) Gender(Required) Male Female Rather not say Height(Required) Weight(Required) Health Profile Rating System - Section 1Rate each of the following to the best of your ability based on your typical health profile over the last year. If you cannot answer a question, simply leave it blank. 0 = Never had symptom 1 = Occasionally have it, mild effect 2 = Occasionally have it, sever effect 3 = Frequently have it, mild effect 4 = Frequently have it, severe effectAnxiety01234Mood Swings01234Enraged behavior or anger for no reasonFirst ChoiceSecond ChoiceThird ChoiceExcessive shyness, timidity, social phobia (not typical to your persanality)01234Irritability (not typical to your personality)01234Low body temperature (below 97.5 F)01234Insomnia (can't get to sleep or return to sleep)01234Dizziness01234Sound in ears (ringing or hearing your heart beat)01234Psychological symptoms, even thoughts of suicide01234Sensitivity to sound01234HiddenSection 1 TotalHealth Profile Rating System - Section 2Indecisiveness01234Feeling of being overwhelmed or fearful01234Metallic taste in your mouth01234Bad Breath01234Bleeding gums01234Sensitive teeth01234Canker sores or other sores in the mouth01234Floaters, shadows or swimmers when you read or look into the sky01234Dyslexia or loss of place while reading, even as a child01234Swelling eyelids01234Peeling on the top later of skin (hands, feet)01234Dry skin01234Heart pain (angina) and you are under 45 years old01234Depression01234Gout (arthritic pain, especially in big toes)01234Pain in shoulders or upper back01234Twitching eyelids01234Anemia (low iron/hemoglobin on blood test)01234Wrist/ankle drop or weak extensor muscles01234Hair falls out (not normal male pattern baldness)01234HiddenSection 2 TotalHealth Profile Rating - Section 3Sensitivity to light01234Fatigue after exercising (feeling worse)01234Bad night vision or seeing halos around lights01234Shortness of breath, with very little effort01234Excessive thirst and/or frequent urination01234Red eyes or tearing01234Blurred vision at times01234Morning stiffness01234Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners01234Chronic fatigue or weakness01234Non-restful sleep01234HiddenSection 3 TotalHealth Profile Rating System - Section 4Receive static shock more often and with more dramatic effect than normal (doorknobs, car, light switch, people, etc.)01234Trouble processing new information01234Word reversal or trouble finding words01234Sensitivity to touch01234Short-term memory loss01234Chronic sinus congestion01234Dry non-productive cough01234Muscle twitching01234Excessive sweating, especially at night01234Joint pain-not necessarily true arthritis-can move from joint to joint01234Difficulty losing weight regardless of diet or exercise01234Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis01234Frequent illness, prolonged illness or sick days01234Numbness or weakness in arms and legs01234Headaches01234Trouble adding or dividing numbers in your head01234Flunctuating constipation and diarrhea01234Stomach pain for no apparent reason01234Appetite swings01234Frequent muscle aches, cramps, unusual sharp sudden pains01234Rashes or rosacea01234Cold extremities (hands and feet)01234HiddenSection 4 TotalPoint Scale Total
