TOXIC BURDEN FOLLOW-UP QUESTIONNAIRE

This questionnaire documents follow-up symptom changes over time. It is for documentation only and does not provide diagnosis or treatment 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

PATIENT INFORMATION

Patient record name / preferred identifier (optional)

Name and relationship of person completing this form

CURRENT STATUS

Current chief complaint

Comments on changes since last visit

MEDICATIONS AND SUPPLEMENTS

List all current medications and supplements taken, including dosage and frequency

Supplements or protocol items not taken at target dose

List any recommended supplements, medications, or protocol items that were stopped, skipped, taken inconsistently, or taken below the recommended dose.

Any problems or issues with compliance?

DIET

Has diet changed since the prior visit? If so, please describe

GENERAL COMMENTS OR FEEDBACK

General comments, questions, concerns, or feedback

For each symptom row, select one: Improved · Worsened · No Change · N/A

TOXIC BURDEN

TOXIN EXPOSURE

Symptom	Improved	Worsened	No Change	N/A
History of living or working in a moldy or water-damaged environment	Improved	Worsened	No Change	N/A
Use of well water or concern about water quality	Improved	Worsened	No Change	N/A
Regular exposure to chemicals such as cleaners, pesticides, plastics, or fragrances	Improved	Worsened	No Change	N/A
History of working with metals, welding, or industrial materials	Improved	Worsened	No Change	N/A
Frequent use of prescription or over-the-counter medications	Improved	Worsened	No Change	N/A
Diet high in processed or packaged foods	Improved	Worsened	No Change	N/A

INFECTIONS / GUT / MOLD

Symptom	Improved	Worsened	No Change	N/A
Frequent sinus congestion or chronic nasal symptoms	Improved	Worsened	No Change	N/A
Recurrent infections such as sinus, respiratory, or urinary infections	Improved	Worsened	No Change	N/A
History of mold exposure with ongoing symptoms	Improved	Worsened	No Change	N/A
History of tick bites or Lyme disease	Improved	Worsened	No Change	N/A
Ongoing digestive issues such as bloating, gas, or irregular stools	Improved	Worsened	No Change	N/A
History of antibiotic use followed by persistent gut issues	Improved	Worsened	No Change	N/A

ENERGY / FATIGUE

Symptom	Improved	Worsened	No Change	N/A
Fatigue not improved by sleep	Improved	Worsened	No Change	N/A
Feeling worse after physical or mental activity	Improved	Worsened	No Change	N/A
Brain fog, especially after concentration	Improved	Worsened	No Change	N/A
Low stamina or easily exhausted	Improved	Worsened	No Change	N/A
Muscle weakness or heaviness	Improved	Worsened	No Change	N/A
Difficulty tolerating heat	Improved	Worsened	No Change	N/A

MUSCLE / RECOVERY

Symptom	Improved	Worsened	No Change	N/A
Low muscle mass or difficulty building muscle	Improved	Worsened	No Change	N/A
Physical fatigue with minimal exertion	Improved	Worsened	No Change	N/A
Weakness or reduced strength	Improved	Worsened	No Change	N/A
Poor exercise tolerance	Improved	Worsened	No Change	N/A
Slow recovery after physical activity	Improved	Worsened	No Change	N/A
History of high physical stress or exertion	Improved	Worsened	No Change	N/A
Mental exhaustion after effort or concentration	Improved	Worsened	No Change	N/A

STRESS / OVERLOAD

Symptom	Improved	Worsened	No Change	N/A
Constant inner tension or feeling “wired”	Improved	Worsened	No Change	N/A
Racing thoughts or inability to relax	Improved	Worsened	No Change	N/A
High stress levels for extended periods	Improved	Worsened	No Change	N/A
Feeling physically or mentally burned out	Improved	Worsened	No Change	N/A
History of needing multiple supplements to feel stable	Improved	Worsened	No Change	N/A

DIET / HYDRATION

Symptom	Improved	Worsened	No Change	N/A
Low vegetable intake	Improved	Worsened	No Change	N/A
Diet high in carbohydrates, sugar, or processed foods	Improved	Worsened	No Change	N/A
Frequent dry mouth	Improved	Worsened	No Change	N/A
Infrequent urination	Improved	Worsened	No Change	N/A
Sedentary lifestyle or low physical activity	Improved	Worsened	No Change	N/A
Tendency toward weight gain, especially around the abdomen	Improved	Worsened	No Change	N/A

DETOX / SENSITIVITY

Symptom	Improved	Worsened	No Change	N/A
Taking three or more prescription or over-the-counter medications daily	Improved	Worsened	No Change	N/A
Sensitivity to medications or supplements	Improved	Worsened	No Change	N/A
Feeling worse when trying new supplements	Improved	Worsened	No Change	N/A
Sensitivity to smells, chemicals, or environments	Improved	Worsened	No Change	N/A
Joint pain, skin issues, or other signs of inflammation	Improved	Worsened	No Change	N/A
Poor recovery after illness or stress	Improved	Worsened	No Change	N/A