5E Tox Quiz

1. Your Name^*

2. Your Mobile Number^*

3. Your Email ID^*

1. Nausea or vomiting^*

2. Diarrhea or loose stool^*

3. Constipation^*

4. Bloated feeling^*

5. Belching/passing gas through anus ^*

6. Heartburn/ Acidity^*

7. Intestinal/Stomach pain^*

1. Irregular or skipped heartbeat^*

2. Rapid or pounding heartbeat^*

3. Chest pain^*

1. Pain or aches in joints^*

2. Swelling in joints^*

3. Stiffness or limitation of movement^*

4. Pain or aches in muscles^*

5. Feeling of weakness or tiredness^*

1. Chest congestion^*

2. Asthma, bronchitis^*

3. Shortness of breath^*

4. Difficult breathing^*

1. Difficulty in recalling from memory^*

2. Confusion, poor comprehension ^*

3. Poor concentration ^*

4. Poor physical coordination^*

5. Difficulty in making decisions ^*

6. Stuttering or stammering^*

7. Slurred speech (not clear speech)^*

8. Learning disabilities (takes time to learn)^*

1. Chronic coughing^*

2. Gagging, frequent need to clear throat^*

3. Sore throat, hoarseness, loss of voice ^*

4. Swollen/discolored tongue, gum, lips^*

5. Mouth Ulcer^*

1. Blocked nose^*

2. Sinus problems^*

3. Itchy nose^*

4. Sneezing attacks^*

5. Excessive mucus formation^*

1. Itchy ears^*

2. Earaches, ear infections^*

3. Drainage from ear^*

4. Ringing in ears^*

5. Hearing loss^*

1. Headaches^*

2. Faintness (blackout)^*

3. Dizziness (light headed)^*

4. Insomnia (lack of sleep)^*

1. Intensity of Mood swings (0 very less - 4 very intense)^*

2. Anxiety, fear or nervousness^*

3. Anger, irritability, or aggressiveness ^*

4. Depression^*

1. Fatigue, sluggishness, tiredness^*

2. Apathy, lethargy^*

3. Hyperactivity- increased need to move ^*

4. Restlessness- in body parts ^*

1. Watery or itchy eyes^*

2. Swollen, reddened or sticky eyelids^*

3. Bags or dark circles under eyes^*

4. Blurred vision (does not include near-or far-sightedness) ^*

1. Acne^*

2. Hives, rashes, or dry skin^*

3. Hair loss^*

4. Flushing or hot flushes^*

5. Excessive sweating^*

1. Binge eating/drinking^*

2. Craving certain foods (0 very little craving - 4 very intense craving) ^*

3. Weight Gaining Tendency (0 limited tendency- 4 very strong tendency) ^*

4. Compulsive eating (0 very less tendency- 4 very intense compulsion) ^*

5. Water retention tendency in the body (0 very less tendency- 4 very intense water retension)^*

6. Weight loss tendency (0 very less tendency- 4 very intense weight loss)^*

1. Frequency of illness (0 very rare- 4 very often) ^*

2. Frequent or urgent urination (0 very rare- 4 very often) ^*

3. Genital itch or discharge^*