Toxin Overload Survey | Natural Balance Health Consulting

Name*

E-mail*

CLUES THAT YOU MAY HAVE REDUCED CHEMICAL METABOLISM

Does caffeine keep you up at night?

Yes
No

Do you smell odors when others cannot?

Yes
No

Do you have known sensitivities to chemicals?

Yes
No

Do you often lower the regular dose of medications because you were too sensitive to the normal dose?

Yes
No

Do you have a sudden onset of symptoms (headaches, skin rashes, nausea, fatigue, etc.) on exposure to:

Chemicals
Mold
Dust
Pollens
Other environmental allergens

SYMPTOMS RELATED TO TOXIC EXPOSURE

Check the box if you suffer from any of the following:

Does central air or heat cause you to feel sick?

Yes
No

Do you feel better when you are outside your home?

Yes
No

DISEASES RELATED TO TOXIC EXPOSURE

Please check off the box if you suffer from any of these diseases

Are you having trouble finding help in the conventional medical model?

Yes
No

Do you want to get your health back on track?

Yes
No

Are you trying to make changes to better your health but are overwhelmed with the challenge of it all? Would you like a support system as you make changes to your health and lifestyle?

Yes
No

Do you want to take control of your health?

Yes
No

Would you be interested in a free 15-minute consultation with Deb?*

Yes
No

Dr. Deborah Oleynik, ND

DO YOU HAVE TOXIN OVERLOAD?