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Worksheet

Neurotoxic Assessment Form

This Neurotoxic Assessment will show us the root causes you may be dealing with and what has caused your perfect storm. Dr. Pompa created it, and it will help us learn from your symptoms. Let's do this. 

1. ➜

Full name

2. ➜

Date

3. ➜

Gender at birth

Important to know your physiology 

4. ➜

Occupation

5. ➜

Email

6. ➜

DOB

7. ➜

Age

8. ➜

Height

9. ➜

Weight

10. ➜

Lives with

11. ➜

Employer Work Address

12. ➜

Education

13. ➜

In Case of an Emergency who should I call and phone number

14. ➜

How did you hear about this wellness program

15. ➜

What is your major complete? Please list all your symtoms and when they started. Please be as detailed as possible.

16. ➜

What are your current medications?

17. ➜

What are your current Suppliments?

18. ➜

Please list your current and past health conditions.

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19. ➜

Is there anything else in your medical history that you consider to be relevant? (Even from childhood)

20. ➜

What is your employment history? Please provide brief summary including dates if possible.

21. ➜

Please list your past or present Hobbies that could be sources of toxicity or chemicals:

22. ➜

How often are you involved in these Hobbies currently?

23. ➜

Please list past or present allergies, including allergies to medications.

24. ➜

Please list all past surgeries and the condition each surgery was for, including dates.

25. ➜

Please explain your housing history (type of homes, where and when).

26. ➜

MERCURY

Check any that apply to you. 

27. ➜

LEAD

Check any that apply to you. 

28. ➜

GENERAL TOXICITY

Please check all that apply to you

29. ➜

Is there any other chemical or toxic exposure you can think of that you have been exposed to.

30. ➜

MOLD

How old is the house you live in?

31. ➜

How long have you lived there?

32. ➜

Have you noticed any new symptoms since moving in?

33. ➜

If so, what?

34. ➜

Do you see mold growing at home, work or school?

35. ➜

Have you ever had water damage at home, work or school?

36. ➜

Does your home, workplace or school have a damp or mildew smell?

37. ➜

Does spending time in your basement cause or worsen your symptoms?

38. ➜

Does your basement ever get wet?

39. ➜

Do you have a crawl space?

40. ➜

Does your basement or crawl space have a sump pump?

41. ➜

Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?

42. ➜

Does your car have a mildew smell?

43. ➜

Does anyone in your home have asthma like symptoms?

44. ➜

Does anyone in your family have chronic sinus infections or irritations?

45. ➜

LYME DISEASE

Have you ever been diagnosed with Lyme Disease? 

46. ➜

Have you had dry sockets or infected tooth extractions?

47. ➜

Do you have small joint pain?

48. ➜

Have you ever been bitten by a tick or recluse spider?

49. ➜

Have you ever seen a bulls-eye rash appear on any part of your body?

50. ➜

Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors?

51. ➜

Was your mother ever diagnosed with Lyme Disease?

52. ➜

Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition?

53. ➜

Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

54. ➜

HEALTH HISTORY

Have any members of your family been diagnosed with fibromyalgia, chronic fatigue, or multiple chemical sensitivities?  

55. ➜

Does anyone in your family experience similar symptoms to yours? What is your birth order (i.e. first born, second, third, etc.)?

56. ➜

Do you have any history of kidney dysfunction?

57. ➜

Do you or any immediate family member have a history with cancer?

58. ➜

Do you have any history of heart disease, myocardial infarction (heart attack), etc.?

59. ➜

Are you currently having any thoughts of suicide?

60. ➜

Have you ever been diagnosed with bipolar disorder, schizophrenia or depression?

61. ➜

Do you have a history of strokes?

62. ➜

Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?

63. ➜

Have you ever been in an auto accident, fallen or received a major physical injury?

64. ➜

Are you in menopause?

65. ➜

MICROBIOME HEALTH

Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, Brussels sprouts, or other vegetables?  

66. ➜

Do you often have gas that has a sulfur or foul smell?

67. ➜

Are you sensitive to supplements?

68. ➜

Have you ever been vegan or vegetarian for any length of time?

69. ➜

Can you tolerate Meat?

70. ➜

Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?

71. ➜

Have you taken birth control or Hormone replacement therapy for any length of time?

72. ➜

If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

73. ➜

Have been on antibiotics for any extended period of time or often as a child or adult?

74. ➜

Were you caesarian delivered?

75. ➜

Were you breast fed? If so, How long?

76. ➜

Does your gut temporarily feel better after a round of antibiotics?

77. ➜

How many times a day are you having a bowel movement?

78. ➜

Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank.

Point Scale 

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
79. ➜

Anxiety

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
80. ➜

Mood Swings

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
81. ➜

Sensativity to light

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
82. ➜

Fatigue after excersizing

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
83. ➜

Enraged behavior or anger for no reason

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
84. ➜

Bad night vision or halos around lights

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
85. ➜

Excessive shyness, timidity, social phobia (not typical to your personality)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
86. ➜

Shortness of breath, with very little effort

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
87. ➜

Irritability (not typical to your personality)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect.
88. ➜

Excessive thirst and/or frequent urination.

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
89. ➜

Low body temperature (below 97.5o)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
90. ➜

Red eyes or tearing

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
91. ➜

Insomnia (can’t get to sleep or return to sleep.

 

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
92. ➜

Blurred vision at time

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
93. ➜

Dizziness

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
94. ➜

Morning stiffness

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
95. ➜

Sound in ears (ringing or hearing your heart beat)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
96. ➜

Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
97. ➜

Psychological symptoms, even thoughts of suicide

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
98. ➜

Chronic fatigue or weakness

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
99. ➜

Sensitivity to sound

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
100. ➜

Non-restful sleep

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
101. ➜

Indecisiveness

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
102. ➜

Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
103. ➜

Feeling of being overwhelmed or fearful

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
104. ➜

Trouble processing new information

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
105. ➜

Metallic taste in your mouth

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
106. ➜

Word reversal or trouble finding words

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
107. ➜

Bad Breath

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
108. ➜

Sensativity to touch

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
109. ➜

Bleeding gums

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
110. ➜

Short-Term memory loss

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
111. ➜

Sensitive teeth

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
112. ➜

Chronic sinus congestion

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
113. ➜

Cancor sores or other sores in the mouth

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
114. ➜

Dry un-productive cough

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
115. ➜

Floaters, shadows or swimmers when you read or look into the sky

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
116. ➜

Muscle twitching

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
117. ➜

Dyslexia or loss of place while reading, even as a child

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
118. ➜

Excessive sweating, especially at night

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
119. ➜

Swelling eyelids

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
120. ➜

Joint pain-not necessarily true arthritis-can move from joint to joint

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
121. ➜

Peeling on top layer of skin (hands, feet

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
122. ➜

Difficulty losing weight regardless of diet or exercise

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
123. ➜

Dry Skin

 

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
124. ➜

Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
125. ➜

Heart pain (angina) and you are under 45 years old

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
126. ➜

Frequent illness, prolonged illness or sick day

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
127. ➜

Depression

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
128. ➜

Numbness or weakness in arms and legs

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
129. ➜

Gout (arthritic pain, especially in big toes)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
130. ➜

Headaches

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
131. ➜

Pain in shoulders or upper back

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
132. ➜

Trouble adding or dividing numbers in your head

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
133. ➜

Twitching eyelids

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
134. ➜

Fluctuating constipation and diarrhea

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
135. ➜

Anemia (low iron/hemoglobin on blood test)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
136. ➜

Stomach pain for no apparent reason

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
137. ➜

Wrist/ankle drop or weak extensor muscles

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
138. ➜

Appetite swings

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
139. ➜

Hair falls out (not normal male pattern baldness)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
140. ➜

Frequent muscle aches, cramps, unusual sharp sudden pain

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
141. ➜

Rashes or rosacea

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
142. ➜

Cold extremities (hands and feet)

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect
143. ➜

Total amount added from all the check boxes, starting at anxiety.

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