Heavy Metal Questionnaire Part 1 of 2

This questionnaire is confidential! The questions that you answer and the results of this test will only be seen by you and are not sent to our office nor will be reviewed by our office. Each response that you give will be assessed by our exclusive Health Evaluation Program and your results will be given at the conclusion of this test. Please feel free to contact our office if you have any questions or would like additional assistance with your results.

This test is a simple Yes or No test, Answer "yes" if the symptom(s) apply to you...Answer "no" if it does not.
Finally Click on Continue to part 2... to get to the next part of the test.

Special Note: You don't have to have all of the symptoms on a question for the question to apply. If you have any one of the symptoms then mark that question Yes...

 

Your Name

No
Yes
  
1.) Social Deficits or Social Withdrawl
2.) Repetitive, perseverative, sterotyped behaviors (OCD-typical behaviors)
3.) Depression, mood swings, flat affect (impaired facial recognition)
4.) Schizoid tendencies (Hallucinations; Delirium)
5.) Irratability, aggressive behaviors, temper tantrums
6.) Suicidal Behaviors
7.) Sleep difficulties / disturbances
8.) Chronic fatigue (CFS) (weakness, malaise)
9.) Anorexia (symptoms reflecting eating disorders, loss of appetite / weight)
10.) Anxiety (nervous tendencies)
11.) Attention problems (ADD, ADHD) lacks eye contact, impaired visual fixation
12.) Speech disorders
13.) Loss of speech, developmental problems with language
14.) Speech comprehension defeicts
15.) Dysarthria (articulation problems) (slurred speech, unintelligible speech)
16.) Mental retardation, borderline intelligence
17.) Uneven performance on IQ scores, low IQ scores
18.) Poor concentration, attention deficits (ADD, ADHD), response inhibition
19.) Poor Memory (short term, verbal, or auditory)
20.) Difficulties understanding abstract ideas (difficulty carrying out complex commands)
No Yes  
21.) Dementia (pre-senile and senile dementia)
22.) Stupor
23.) Impaired reaction time (lower performance on timed tests)
24.) Abnormal Sensations in the mouth and extremeties
25.) Hearing loss, difficulty hearing
26.) Abnormal touch sensations; diminished touch sensations, aversion to touch
27.) Blurred vision (sensitivity to light)
28.) Choreiform movements, myoclonal jerks, unusual postures
29.) Difficulty walking, swallowing, talking
30.) Flapping, curcling, rocking, toe walking
31.) Problems with intentional movements or imitation
32.) Abnormal gait/posture (incoordination, loss of balance; problems sitting, lying, crawling, and walking)
33.) Decreased locomotor activity
34.) Convulsions (seizure)
35.) Neurofibrillary tangles
36.) Neuritis, retrobulbar neuritis (neuropathy)
37.) Encephalopathy
38.) Cerebrovascular disease
39.) Alterations in nerve conduction velocity