Medical Symptom/Toxicity Questionnaire

MEDICAL SYMPTOM/TOXICITY QUESTIONNAIRE

Complete this self-check to connect your symptoms with potential health factors.

Xenobiotic Tolerability Test (XTT)

This test helps measure your body’s tolerance to chemicals, medications, and environmental toxins.

Step 1 of 16

HEAD

0 = Never or almost never have the symptom; 1 = Occasionally have it, effect is not severe; 2 = Occasionally have, effect is severe; 3 = Frequently have it, effect is not severe; 4 = Frequently have it, effect is severe

Headaches(Required)

Faintness(Required)

Dizziness(Required)

Insomnia(Required)

Medical Symptom/Toxicity Questionnaire

MEDICAL SYMPTOM/TOXICITY QUESTIONNAIRE

Xenobiotic Tolerability Test (XTT)

HEAD

EYES

EARS

NOSE

MOUTH/THROAT

SKIN

HEART

LUNGS

DIGESTIVE TRACT

JOINTS/MUSCLES

WEIGHT

ENERGY/ACTIVITY

MIND

EMOTIONS

OTHER

	0	1	2	3	4
Past Month
Past Week
Past 48 hours

	0	1	2	3	4
Past Month
Past Week
Past 48 hours

	0	1	2	3	4
Past Month
Past Week
Past 48 hours

	0	1	2	3	4
Past Month
Past Week
Past 48 hours