Rate each of the following symptoms based upon your health profile for the past 14 DAYS.

POINT SCALE

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

KEY TO QUESTIONNAIRE
Add individual scores and total each group, Add each group scores and give a grand total.

• Optimal is less than 10
• Mild Toxicity: 10-50 
• Moderate Toxicity: 50-100
• Severe Toxicity: over 100