PERSONALIZED TOXICITY REPORT


Do you struggle with weight loss/gain? 

Are you suffering from fatigue, low libido or stamina? 

Do you experience nausea, headaches or insomnia? 

Is your diet unhealthy?  

Are you toxic? Find out NOW! 

MBS is the only company to offer a FREE personalized toxicity report, based on your body type, with the purchase of a 10 or 21 day body detox diet kit.

You are one step away from receiving your FREE toxicity report (A $98 value)  

The Toxicity Questionnaire is designed to help you understand what toxins are inside your body, and how you can reverse the negative effects associated with diet and the environment. We encourage you and your friends & family to take advantage of this FREE toxicity report while the offer lasts. “Your health could depend on it!”  

It’s fast and FREE! Once you’ve purchased your 10 or 21 day body detox diet kit online, simply complete and submit the form below and your personalized toxicity report will arrive via email within 24 hrs. If you have not received your report within 24 hours, please contact MBS at 469-569-5422  

Thank you, and LIVE WELL!  
FIRST: PLEASE PROVIDE US WITH YOUR CONTACT INFORMATION

* required 		 
Name*:
Phone*:
  
Email*:
  
Validate Email*:
  
How did you hear about the program?*:
Additional Comments, Health Issues and/or Medications, if any:

Section I:  Symptoms

Rate each of the following symptoms based upon your health profile for the past 90-180 days.

Mark the corresponding number

0  Rarely or never experience the symptom

  

1  Occasionally experience the symptom

 Effect not severe

2  Occasionally experience the symptom

 Effect severe

3  Frequently experience the symptom

 Effect not severe

4  Frequently experience the symptom

 Effect severe
1. Digestion

0

1

2

3

4
a. Nausea and/or vomiting
b. Diarrhea
c. Constipation
d. Bloated
e. Belching and/or passing gas
f. Heartburn
          total:  
2. Ears

0

1

2

3

4
a. Itchy ears
b. Ear aches, ear infections
c. Drainage from ear
d. Ringing in ears/hearing loss
          total:
3. Emotions

0

1

2

3

4
a. Mood swings
b. Anxiety, fear, nervousness  
c. Anger, irritability  
d. Depression
e. Sense of despair
f.; Apathy/lethargy
          total:  
4. Energy/Activity

0

1

2

3

4
a. Fatigue/sluggishness
b. Hyperactivity
c. Restlessness
d. Insomnia
e. Startled awake at night
          total:
5. Eyes

0

1

2

3

4
a. Watery/itchy eyes
b. Swollen, reddened, sticky eyelids
c. Dark circles under eyes
d. Blurred/tunnel vision
          total:
6. Head

0

1

2

3

4
a. Headaches
b. Faintness
c. Dizziness
d. Pressure
          total:
7. Lungs

0

1

2

3

4
a. Chest congestion
b. Asthma/bronchitis
c. Shortness of breath
d. Difficulty breathing
          total:
8. Mind

0

1

2

3

4
a. Poor memory
b. Confusion
c. Poor concentration
d. Poor coordination
e. Difficulty making decisions
f. Stuttering, stammering
g. Slurred speech
h. Learning disabilities
          total:
9. Mouth/throat

0

1

2

3

4
a. Chronic coughing
b. Gagging
c. Frequent need to clear throat
d. Swollen, discolored tongue, gums, lip
e. Canker sores
          total:
10. Nose

0

1

2

3

4
a. Stuffy nose
b. Sinus problems
c. Hay fever
d. Sneezing attacks
e. Excessive mucous
          total:
11. Skin

0

1

2

3

4
a. Acne
b. Hives, rashes, dry skin
c. Hair loss
d. Flushing
e. Excessive sweating
          total:
12. Heart

0

1

2

3

4
a. Skipped heartbeats
b. Rapid heartbeats
c. Chest pain
          total:
13. Joints/Muscles

0

1

2

3

4
a. Pain or aches in joints
b. Rheumatoid arthritis
c. Osteoarthritis
d. Stiffness, limited movement
e. Pain or aches in muscles
f. Recurrent back aches
g. Feeling of weakness or tiredness
          total:
14. Weight

0

1

2

3

4
a. Binge eating/drinking
b. Craving certain foods
c. Excessive weight
d. Compulsive eating
e. Water retention
f. Under weight
          total:
15. Other

0

1

2

3

4
a. Frequent illnesses
b. Frequent/urgent urination
c. Leaky bladder
d. Genital itch/discharge
          total:

Section I total:

Section II:  Risk of Exposure

16. Mark the corresponding number for question 16a-f below 0 never 1 rarely 2 monthly 3 weekly 4 daily
a. How often are strong chemicals used in your home?
(disinfectants, bleaches, oven & drain cleansers, furniture polish, floor wax, window cleaners, etc.)		  
b. How often are pesticides used in your home?  
c. How often is your home treated for insects?   
d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense or varnish in home/office?   
e. How often are you exposed to nail polish, perfume, hair spray, and other cosmetics?    
f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?  
          total:  
17. Mark the corresponding number for question 17a-b below 0 No
change		 1 Mild
change		 2 Moderate change 3 Drastic change
a. Have you noticed any negative change in your health since you moved into your home or apartment?
b. Have you noticed any negative change in your health since you started your new job?
        total:  
18. Mark the corresponding number for question 18a-d below Yes No
a. Do you have a water purification system in your home?
b. Do you have any indoor pets?
c. Do you have an air purification system in your home?
d. Are you a dentist, painter, farm or construction worker?
 
Grand Total Sections I + II:                 
total:

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