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)
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)
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.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) 
6.Do you drink filtered water?
Always or mostly (0)
Sometimes (1) 
Never or rarely (2)
7.How often would you have tinned food?
Never or rarely (0)
Monthly (1) 
Weekly (2) 
Daily (3)
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) 
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)
10.Do you use 'social' or 'recreational' drugs? (e.g. marijuana, ecstasy, etc.)
Never (0)
Rarely (1)
Monthly (3) 
Weekly (4) 
Daily (5) 
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) 
12.Do you feel unusually tired?
Never (0) 
Sometimes (1) 
Often (3) 
Always (5) 
13.Do you have any skin issues? (e.g. acne, eczema, rashes)
None (0)
Slight (1) 
Moderate (2) 
Severe (4) 
14.Do you suffer from headaches or migraines?
Never or rarely (0) 
Monthly (3) 
Weekly (4) 
Daily (5) 
15.Do you suffer from allergies or asthma?
None (0) 
Slight (1) 
Moderate (3) 
Severe (5) 
16.Total Score for Section 1a (please tally and enter)(Required.)