ASN Toxicity Questionnaire
Section 1a Diet, Lifestyle, Symptoms and Medical History
1.
What is your full name?
2.
How much of the food you eat each week is 'spray-free' or organically grown or raised?
All or most (0)
Around half (2)
Some (4)
None (5)
All or most (0)
Around half (2)
Some (4)
None (5)
Score
3.
How often do you eat fruit?
One serve = one handful
2 or more serves a day (0)
1 serve daily (1)
Weekly (3)
Monthly (4)
Never or rarely (5)
2 or more serves a day (0)
1 serve daily (1)
Weekly (3)
Monthly (4)
Never or rarely (5)
Score
4.
How often do you eat vegetables (excluding potatoes)?
One serve = one handful
5 or more serves daily (0)
2-4 serves daily (1)
Daily (2)
Weekly (3)
Monthly (4)
Never or rarely (5)
5 or more serves daily (0)
2-4 serves daily (1)
Daily (2)
Weekly (3)
Monthly (4)
Never or rarely (5)
Score
5.
How often do you eat animal products? (e.g. dairy foods, eggs, poultry, red meat or fish)
Never or rarely (0)
Monthly (1)
Weekly (2)
Once a day (3)
Twice daily (4)
Most meals (5)
Never or rarely (0)
Monthly (1)
Weekly (2)
Once a day (3)
Twice daily (4)
Most meals (5)
Score
6.
Do you drink filtered water?
Always or mostly (0)
Sometimes (1)
Never or rarely (2)
Always or mostly (0)
Sometimes (1)
Never or rarely (2)
Score
7.
How often would you have tinned food?
Never or rarely (0)
Monthly (1)
Weekly (2)
Daily (3)
Never or rarely (0)
Monthly (1)
Weekly (2)
Daily (3)
Score
8.
How often do you eat 'fast' or 'junk' food? (e.g. takeaway, deep fried, snack food)
Never or rarely (0)
Monthly (1)
Weekly (3)
Daily (5)
Never or rarely (0)
Monthly (1)
Weekly (3)
Daily (5)
Score
9.
How often do you drink more than 4 standard alcoholic drinks in one session?
Never or rarely (0)
Monthly (2)
Weekly: 1-2 times (3)
Weekly: 3-6 times (4)
Daily (5)
Never or rarely (0)
Monthly (2)
Weekly: 1-2 times (3)
Weekly: 3-6 times (4)
Daily (5)
Score
10.
Do you use 'social' or 'recreational' drugs? (e.g. marijuana, ecstasy, etc.)
Never (0)
Rarely (1)
Monthly (3)
Weekly (4)
Daily (5)
Never (0)
Rarely (1)
Monthly (3)
Weekly (4)
Daily (5)
Score
11.
How many 'personal care' products do you use? (e.g. soap, cleanser, shampoo, conditioner, antiperspirants, moisturiser, special creams, cosmetics: foundation, eyeliner, eyeshadow, lipstick, perfumes)
0-5 products daily (0)
6-10 products daily (2)
11-20 products daily (4)
21 or more products daily (5)
0-5 products daily (0)
6-10 products daily (2)
11-20 products daily (4)
21 or more products daily (5)
Score
12.
Do you feel unusually tired?
Never (0)
Sometimes (1)
Often (3)
Always (5)
Never (0)
Sometimes (1)
Often (3)
Always (5)
Score
13.
Do you have any skin issues? (e.g. acne, eczema, rashes)
None (0)
Slight (1)
Moderate (2)
Severe (4)
None (0)
Slight (1)
Moderate (2)
Severe (4)
Score
14.
Do you suffer from headaches or migraines?
Never or rarely (0)
Monthly (3)
Weekly (4)
Daily (5)
Never or rarely (0)
Monthly (3)
Weekly (4)
Daily (5)
Score
15.
Do you suffer from allergies or asthma?
None (0)
Slight (1)
Moderate (3)
Severe (5)
None (0)
Slight (1)
Moderate (3)
Severe (5)
Score
*
16.
Total Score for Section 1a (please tally and enter)
(Required.)
