Toxic Overload Assessment

This questionnaire screens for patterns of toxic burden, mitochondrial strain, methylation stress, creatine demand, and impaired metabolic clearance.

Select all items that apply. This screening is not diagnostic, but it helps identify whether toxic overload and related metabolic stress may be contributing to symptoms and whether additional testing such as SAM/SAH or more detailed follow-up is justified.

Identification (for reports)

Used to file reports and match prior submissions.

Doctor first name
Doctor last name
Patient first name
Patient last name
Patient cross-reference ID (if known)
Date of birth

Daily Function

Low endurance despite adequate nutrition and sleep #1 Need to rest frequently during normal daily activities #2 Symptoms worsen after physical or mental exertion #3 Mental exhaustion or brain fog after concentration or problem-solving #4 Unrefreshed after sleep despite adequate duration #5 Difficulty maintaining consistent energy throughout the day #6 Increased fatigue in the afternoon or early evening #7

Physical Performance And Recovery

Difficulty building or maintaining muscle mass #8 Reduced strength or low power output #9 Rapid fatigue during short, high-intensity activity #10 Poor recovery between physical efforts #11 Muscle soreness lasting longer than expected #12 Feeling physically drained after mild exertion #13 Decreased tolerance for exercise over time #14

Environmental Sensitivity

Sensitivity to chemicals, perfumes, or cleaning products #15 Poor tolerance to medications, alcohol, or supplements #16 Headaches or symptoms triggered by smells or environments #17 Feeling unwell in enclosed or poorly ventilated spaces #18 Increased symptoms in certain buildings or locations #19 Sensitivity to smoke, fumes, or pollutants #20

Exposure History

Known or suspected mold exposure (home, workplace, or past environment) #21 Exposure to water-damaged buildings #22 Exposure to heavy metals (occupational, dental, environmental) #23 Frequent exposure to chemicals (work or home environment) #24 Use of pesticides, herbicides, or industrial cleaners #25 Drinking unfiltered or well water without testing #26

Inflammation And Immune Stress

Chronic inflammation, pain, or autoimmune symptoms #27 Chronic viral, bacterial, or parasitic infections #28 Frequent illness or slow recovery from infections #29 Skin reactions, rashes, or unexplained inflammation #30 Joint or muscle pain without clear injury #31 Persistent sinus or respiratory issues #32

Stress And Neurological Load

Chronic psychological or emotional stress #33 Poor tolerance to stress #34 Feeling overwhelmed easily #35 Difficulty recovering from stressful events #36 Increased symptoms during periods of stress #37

Metabolic And Dietary Patterns

Diet high in sugar or refined carbohydrates #38 Low intake of vegetables or nutrient-dense foods #39 Blood sugar fluctuations or energy crashes after eating #40 Cravings for sugar or stimulants #41 Bloating, gas, or digestive discomfort after meals #42 Symptoms suggestive of gut imbalance or fermentation #43

Hydration And Detox Support

Low fluid intake or inconsistent hydration #44 Low electrolyte intake despite sweating or activity #45 Poor tolerance to heat or tendency to overheat #46 Reduced sweating or difficulty regulating body temperature #47

Medication And Chemical Load

Long-term use of medications #48 Use of multiple prescription medications simultaneously #49 History of frequent medication changes #50 Regular alcohol consumption #51 Use of stimulants, diuretics, or metabolic medications #52