Initial Biotype and Toxic Burden Questionnaire

This form collects clinical history and symptom responses you select. It is for documentation only. It does not provide a medical diagnosis, assessment, treatment plan, or supplement recommendations.

Identification (for reports)

Doctor first name

Doctor last name

Patient first name

Patient last name

Patient cross-reference ID (if known)

Date of birth

1. Patient Information

Patient ID, DOB, contact info, resp party

Patient record name / preferred identifier (optional)

Patient gender

Primary contact email

Phone

City

State

Country

Name and relationship of person completing this form

2. Primary Complaint

Condition, history, meds and supplements

Primary concern or chief complaint

Relevant clinical history

Prior medical diagnoses

Current medications and supplements

Medications taken for more than 60 days in the past

Family History

Item	Yes	No	N/A
Depression	Yes	No	N/A
Anxiety	Yes	No	N/A
OCD	Yes	No	N/A
Bipolar symptoms	Yes	No	N/A
Schizophrenia	Yes	No	N/A
Autism	Yes	No	N/A
ADHD	Yes	No	N/A
Alcoholism or substance abuse	Yes	No	N/A
Neurodegenerative disease (Parkinson's, Alzheimer's)	Yes	No	N/A
Other (describe)	Yes	No	N/A
Family history — Other (describe)

Early Life and Trauma History

Item	Yes	No	N/A
Difficult pregnancy or birth	Yes	No	N/A
Mother smoked, drank alcohol, or used medications/drugs during pregnancy	Yes	No	N/A
Childhood abuse or neglect	Yes	No	N/A
Adulthood abuse or trauma	Yes	No	N/A
Serious reaction to a vaccine	Yes	No	N/A
Head trauma or concussion	Yes	No	N/A

Childhood Health History

Item	Yes	No	N/A
Frequent antibiotic use	Yes	No	N/A
Frequent medication use	Yes	No	N/A
Delayed growth	Yes	No	N/A
Social interaction difficulties	Yes	No	N/A
Behavioral or violent tendencies	Yes	No	N/A

Tobacco and Substance Use

Item	Yes	No	N/A
Current cigarette use	Yes	No	N/A
Past cigarette use	Yes	No	N/A
Vaping or nicotine products	Yes	No	N/A
Alcohol use (current)	Yes	No	N/A
Alcohol use (past heavy use)	Yes	No	N/A
Past or present use of recreational or street drugs	Yes	No	N/A

Environmental Exposures

Item	Yes	No	N/A
Living or working in a moldy or water-damaged environment	Yes	No	N/A
Use of well water	Yes	No	N/A
Exposure to chemicals (cleaners, pesticides, solvents, plastics)	Yes	No	N/A
Exposure to metals (occupational, welding, industrial materials)	Yes	No	N/A
Sensitivity to smells, chemicals, or environments	Yes	No	N/A
Symptoms that worsen in certain buildings or environments	Yes	No	N/A
Other (describe)	Yes	No	N/A
Environmental exposures — Other (describe)

Typical Daily Intake

Typical breakfast

Typical lunch

Typical dinner

Snacks

Beverages (water, coffee, soda, alcohol, etc.)

Dietary Habits / Food Frequency

Item	Rare	Occasional	Frequent
Corn-based foods	Rare	Occasional	Frequent
Wheat / gluten-containing foods	Rare	Occasional	Frequent
Dairy products	Rare	Occasional	Frequent
Soy products	Rare	Occasional	Frequent
Meat, fish, pork, or chicken	Rare	Occasional	Frequent

Dietary Patterns

Item	Yes	No	N/A
Frequent consumption of sugary foods or desserts	Yes	No	N/A
Frequent consumption of sweetened beverages (soda, juice, energy drinks)	Yes	No	N/A
Frequent fast food intake	Yes	No	N/A
Frequent consumption of processed or packaged foods	Yes	No	N/A
Frequent consumption of processed meats (deli meats, bacon, sausage)	Yes	No	N/A
Frequent consumption of highly flavored or artificial foods	Yes	No	N/A
Other (describe)	Yes	No	N/A
Dietary patterns — Other (describe)

Gut Health

Item	Yes	No	N/A
Bloating	Yes	No	N/A
Gas	Yes	No	N/A
Constipation	Yes	No	N/A
Diarrhea	Yes	No	N/A
Irregular bowel movements	Yes	No	N/A
Food sensitivities	Yes	No	N/A
Nausea (especially morning)	Yes	No	N/A
Reflux or heartburn	Yes	No	N/A
Malodorous (foul-smelling) stool	Yes	No	N/A
Other (describe)	Yes	No	N/A
Gut health — Other (describe)

3. Full biotype questionnaire

For each line, choose Yes only if it applies to you. No and N/A are not counted in the totals on the next page.

Response for each row (right-hand columns): Yes · No · N/A

MOOD AND DEPRESSION

Symptom	Yes	No	N/A
Chronic depression	Yes	No	N/A
Depression with ADHD	Yes	No	N/A
Depression with anxiety	Yes	No	N/A
Depression with poor stress tolerance and social withdrawal	Yes	No	N/A
Emotional meltdowns	Yes	No	N/A
High anxiety	Yes	No	N/A
High irritability	Yes	No	N/A
History of perfectionism	Yes	No	N/A
Insomnia	Yes	No	N/A
Mild to moderate irritability	Yes	No	N/A
Obsessions without compulsive actions	Yes	No	N/A
OCD - Obsessive Compulsive tendencies	Yes	No	N/A
Panic tendency	Yes	No	N/A
Paranoia tendency	Yes	No	N/A
Perfectionism	Yes	No	N/A
Phobias	Yes	No	N/A
Poor stress control	Yes	No	N/A
Rumination about past events	Yes	No	N/A
Severe anxiety	Yes	No	N/A
Severe depression	Yes	No	N/A
Severe inner tension	Yes	No	N/A
Short temper	Yes	No	N/A
Suicidal tendencies	Yes	No	N/A

ATTENTION AND BEHAVIOR

Symptom	Yes	No	N/A
Academic underachievement	Yes	No	N/A
ADHD - Attention Deficit Hyperactivity Disorder	Yes	No	N/A
Dietary inflexibility	Yes	No	N/A
History of reading disorder	Yes	No	N/A
History of underachievement	Yes	No	N/A
Hyperactivity	Yes	No	N/A
Low motivation during school years	Yes	No	N/A
Memory loss	Yes	No	N/A
Nervous legs - pacing	Yes	No	N/A
Poor concentration and focus	Yes	No	N/A
Poor concentration endurance	Yes	No	N/A
Poor short term memory	Yes	No	N/A
Rapid speech	Yes	No	N/A
Self motivation during school years	Yes	No	N/A
Talkative	Yes	No	N/A

SLEEP AND ENERGY

Symptom	Yes	No	N/A
Infrequent terse speech	Yes	No	N/A
Insomnia	Yes	No	N/A
Morning nausea	Yes	No	N/A
Stress-related sleep disruption or poor recovery	Yes	No	N/A
Slenderness	Yes	No	N/A
Tendency to delay or skip breakfast	Yes	No	N/A
Tendency to stay up very late	Yes	No	N/A

SENSITIVITIES AND PERCEPTION

Symptom	Yes	No	N/A
Chemical sensitivities	Yes	No	N/A
Dry eyes and mouth	Yes	No	N/A
Food sensitivies	Yes	No	N/A
Low pain tolerance	Yes	No	N/A
Sensitive to bright lights	Yes	No	N/A
Sensitive to loud noises	Yes	No	N/A
Sensitivity to food dyes	Yes	No	N/A
Sensitivity to shellfish	Yes	No	N/A
Skin sensitivity to rough fabrics and clothes tags	Yes	No	N/A

PHYSICAL SIGNS AND APPEARANCE

Symptom	Yes	No	N/A
Delicate facial features	Yes	No	N/A
High fluidity (tears, saliva, etc)	Yes	No	N/A
High pain threshold	Yes	No	N/A
Hirsutism or abnormal hair growth	Yes	No	N/A
Large nose and ears	Yes	No	N/A
Overweight	Yes	No	N/A
Poor muscle development	Yes	No	N/A
Poor wound healing	Yes	No	N/A
Premature graying of hair	Yes	No	N/A
Ringing in ears	Yes	No	N/A
Sparse chest, leg and arm hair	Yes	No	N/A
Stretch marks on skin	Yes	No	N/A
Tendency to be overweight	Yes	No	N/A
Very dry skin	Yes	No	N/A
White spots (clouds) in fingernails	Yes	No	N/A
White spots (clouds) on fingernails	Yes	No	N/A

HISTORY AND TIMELINE

Symptom	Yes	No	N/A
Artistic or musical talent	Yes	No	N/A
Delayed growth	Yes	No	N/A
Family history of high accomplishment	Yes	No	N/A
High accomplishment before onset	Yes	No	N/A
History of competitiveness in sports	Yes	No	N/A
History of post partum depression	Yes	No	N/A
Onset of symptoms during puberty, following pregnancy or menopause	Yes	No	N/A
Poor growth	Yes	No	N/A
Religiosity	Yes	No	N/A

HORMONAL AND ENVIRONMENTAL

Symptom	Yes	No	N/A
Absence of seasonal allergies	Yes	No	N/A
Antihistamine intolerance	Yes	No	N/A
Autoimmune disorder	Yes	No	N/A
Drinks well water - possibly contaminated	Yes	No	N/A
Exposure to copper containing chemicals	Yes	No	N/A
Frequent infections	Yes	No	N/A
Frequent seasonal allergies	Yes	No	N/A
Good response to antihistamines	Yes	No	N/A
Good response to folic acid	Yes	No	N/A
History of copper IUD use	Yes	No	N/A
History of estrogen elevation	Yes	No	N/A
History of hormone therapy or use of birth control pills	Yes	No	N/A
Intolerance to birth control or estrogen	Yes	No	N/A
Use of copper cookware	Yes	No	N/A
Worked with metals such as soldering and welding	Yes	No	N/A

NEUROLOGICAL AND MEDICAL

Symptom	Yes	No	N/A
Abnormal EEG	Yes	No	N/A
Catatonic behavior before onset of illness	Yes	No	N/A
Diagnosis of delusional disorder	Yes	No	N/A
Diagnosis of schizoaffective disorder	Yes	No	N/A
Elevated adrenalin or norepinephrine activity	Yes	No	N/A
Fibromyalgia	Yes	No	N/A
Improvement after lithium	Yes	No	N/A
Joint pains	Yes	No	N/A
Low absolute basophils	Yes	No	N/A
Low blood histamine	Yes	No	N/A
Low dopamine activity	Yes	No	N/A
Poor immune function	Yes	No	N/A
Spleen area pain	Yes	No	N/A

DIGESTIVE AND DIETARY

Symptom	Yes	No	N/A
Affinity for spicy or salty foods	Yes	No	N/A
Dry eyes and mouth	Yes	No	N/A
Food sensitivies	Yes	No	N/A
Morning nausea	Yes	No	N/A
Peptic ulcers	Yes	No	N/A
Sensitivity to shellfish	Yes	No	N/A
Vegetarian diet	Yes	No	N/A

4. Toxic burden / methylation questionnaire

For each line, choose Yes only if it applies to you. No and N/A are not counted in toxic burden category percentages.

Response for each row (right-hand columns): Yes · No · N/A

DAILY FUNCTION

Symptom	Yes	No	N/A
Low endurance despite adequate nutrition and sleep	Yes	No	N/A
Need to rest frequently during normal daily activities	Yes	No	N/A
Symptoms worsen after physical or mental exertion	Yes	No	N/A
Mental exhaustion or brain fog after concentration or problem-solving	Yes	No	N/A
Unrefreshed after sleep despite adequate duration	Yes	No	N/A
Difficulty maintaining consistent energy throughout the day	Yes	No	N/A
Increased fatigue in the afternoon or early evening	Yes	No	N/A

PHYSICAL PERFORMANCE AND RECOVERY

Symptom	Yes	No	N/A
Difficulty building or maintaining muscle mass	Yes	No	N/A
Reduced strength or low power output	Yes	No	N/A
Rapid fatigue during short, high-intensity activity	Yes	No	N/A
Poor recovery between physical efforts	Yes	No	N/A
Muscle soreness lasting longer than expected	Yes	No	N/A
Feeling physically drained after mild exertion	Yes	No	N/A
Decreased tolerance for exercise over time	Yes	No	N/A

ENVIRONMENTAL SENSITIVITY

Symptom	Yes	No	N/A
Sensitivity to chemicals, perfumes, or cleaning products	Yes	No	N/A
Poor tolerance to medications, alcohol, or supplements	Yes	No	N/A
Headaches or symptoms triggered by smells or environments	Yes	No	N/A
Feeling unwell in enclosed or poorly ventilated spaces	Yes	No	N/A
Increased symptoms in certain buildings or locations	Yes	No	N/A
Sensitivity to smoke, fumes, or pollutants	Yes	No	N/A

EXPOSURE HISTORY

Symptom	Yes	No	N/A
Known or suspected mold exposure (home, workplace, or past environment)	Yes	No	N/A
Exposure to water-damaged buildings	Yes	No	N/A
Exposure to heavy metals (occupational, dental, environmental)	Yes	No	N/A
Frequent exposure to chemicals (work or home environment)	Yes	No	N/A
Use of pesticides, herbicides, or industrial cleaners	Yes	No	N/A
Drinking unfiltered or well water without testing	Yes	No	N/A

INFLAMMATION AND IMMUNE STRESS

Symptom	Yes	No	N/A
Chronic inflammation, pain, or autoimmune symptoms	Yes	No	N/A
Chronic viral, bacterial, or parasitic infections	Yes	No	N/A
Frequent illness or slow recovery from infections	Yes	No	N/A
Skin reactions, rashes, or unexplained inflammation	Yes	No	N/A
Joint or muscle pain without clear injury	Yes	No	N/A
Persistent sinus or respiratory issues	Yes	No	N/A

STRESS AND NEUROLOGICAL LOAD

Symptom	Yes	No	N/A
Chronic psychological or emotional stress	Yes	No	N/A
Poor tolerance to stress	Yes	No	N/A
Feeling overwhelmed easily	Yes	No	N/A
Difficulty recovering from stressful events	Yes	No	N/A
Increased symptoms during periods of stress	Yes	No	N/A

METABOLIC AND DIETARY PATTERNS

Symptom	Yes	No	N/A
Diet high in sugar or refined carbohydrates	Yes	No	N/A
Low intake of vegetables or nutrient-dense foods	Yes	No	N/A
Blood sugar fluctuations or energy crashes after eating	Yes	No	N/A
Cravings for sugar or stimulants	Yes	No	N/A
Bloating, gas, or digestive discomfort after meals	Yes	No	N/A
Symptoms suggestive of gut imbalance or fermentation	Yes	No	N/A

HYDRATION AND DETOX SUPPORT

Symptom	Yes	No	N/A
Low fluid intake or inconsistent hydration	Yes	No	N/A
Low electrolyte intake despite sweating or activity	Yes	No	N/A
Poor tolerance to heat or tendency to overheat	Yes	No	N/A
Reduced sweating or difficulty regulating body temperature	Yes	No	N/A

MEDICATION AND CHEMICAL LOAD

Symptom	Yes	No	N/A
Long-term use of medications	Yes	No	N/A
Use of multiple prescription medications simultaneously	Yes	No	N/A
History of frequent medication changes	Yes	No	N/A
Regular alcohol consumption	Yes	No	N/A
Use of stimulants, diuretics, or metabolic medications	Yes	No	N/A