Free Neurotoxicity Assessment for Women Over 40

Tired of Brain Fog, Fatigue, and Joint Pain That Just Won’t Go Away?

Discover the hidden root causes stealing your energy and clarity — without more pills that only mask the symptoms.

If you're a woman over 40 struggling with menopause symptoms, stubborn weight, constant exhaustion, brain fog, or aching joints, you're not alone — and it's not "just aging."

The conventional approach often pushes more medications that cover up what's really happening and can create new health risks.

There is a better way. A natural, science-backed approach that works with your body to address the root causes so you can finally feel clear, energized, and like yourself again.

Scroll down to get your free, confidential neurotoxicity assessment.

What This Free Assessment Can Help You Uncover

Designed especially for women over 40, this gentle yet thorough assessment sheds light on the underlying stressors that may be impacting your brain, hormones, metabolism, and joints.

Uncover the hidden toxins and imbalances most doctors miss
Get a personalized, in-depth report with clear science-based insights
Learn gentle, natural steps designed for your body’s unique needs
Start your journey toward real healing — confidential and judgment-free

Get Your Free Neurotoxicity Assessment Today

This isn’t a basic quiz. It’s a thoughtful, in-depth questionnaire that goes far deeper than typical doctor visits to help identify the root triggers contributing to your fatigue, brain fog, joint pain, and weight struggles.

When you complete the NTA, I’ll personally review and deliver your complete confidential report — packed with science-backed explanations tailored to you.

Simple steps:
1. Enter your name and email below.
2. Please complete all questions that you can for a complete assessment on your health.
3. Everything stays 100% private.

✅ 100% Confidential — Your information and results are safe with me.
✅ No spam — Just real support and helpful insights.
✅ Backed by science and rooted in natural, God-designed healing principles.

You Don’t Have to Keep Pushing Through Alone

You don’t have to keep suffering in silence or settling for temporary fixes. Take this simple first step toward understanding what’s really going on in your body — and finally feeling better.

P.S. Many women tell me this assessment was the first time they truly felt seen and understood. If you're ready for answers and a gentler path forward, click above to request your link and begin today.

NTA - (Neurotoxicity Assessment)

Thank you very much for taking the time to share your experience. Please know that all answers will be kept confidential.

I simply want to make sure that what I am creating for you is on track with what will benefit you the best.

First Name *

Last Name *

Phone *

Email *

DOB

Your Gender: *

Male

Female

Occupation & Hours per Week work

How did you hear about our Wellness & Nutrition Program?

💞Patient History

Answer the following questions to the best of your ability. If you don’t know the answer, simply leave it blank.

What is your primary concern? Please list when each symptom began and be as descriptive as possible:

Please list your current medications.

What is your current vitamin and/or supplements:

Please list your current & past health conditions (i.e. Diabetes Mellitus, etc):

Is there anything else in your medical history that you consider to be relevant? (Even from your Childhood):

What is your employment history? Please provide brief summary:

Please list your past - present Hobbies that could be sources of toxicity or chemicals:

How often are you involved in these Hobbies now:

Please list past - present allergies, including allergies to medications:

Please list all past surgeries & condition each surgery was for, including dates:

Please explain your housing history (type of homes, where & when):

💥Mercury

Do you have any amalgam (silver) fillings in your teeth?

Yes

If so, How Many Filings?

Have you ever had an amalgam filling removed?

Yes

If yes, How many and Date removed?

If you had amalgams fillings removed, was it done by a biological dentist using a safe protocol?

Yes

Did your mother have any amalgam when pregnant with you?

Yes

Have you ever worked for a dental office?

Yes

If so, How long did you work their?

Do you had any dental crowns?

Yes

If so, how many crowns?

Do you had any bridges?

Yes

Have you had dry sockets or infected tooth extractions?

Yes

Do you had any root canals?

Yes

Did you have any tooth extractions?

Yes

Did you have any dental implants, retainers or other metal in your mouth?

Yes

Did you wear contact lenses during the 1980's or early 1990's?

Yes

Did you take oral contraceptives during the 1980's or early 1990's?

Yes

Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination?

Yes

Have you noticed any adverse reactions to these shots?

Yes

Do you have any tattoos with red ink?

Yes

Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon?

Yes

🌿Lead

Does your occupation involve soldering or metal salvage?

Yes

Have you done any old home repaid or sandblasting?

Yes

If so , when?

Do you do a lot of painting?

Yes

Was your home built before 1978?

Yes

Option 3

Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment)

Yes

Are you around a lot of fake leather, or vinyl?

Yes

Do you get stomach aches in the morning?

Yes

Option 3

✨General Toxicity

Have you ever lived near, or or by a golf course, freeway or tension wires?

Yes

Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.)

Yes

Do you have your house sprayed with pesticides for pest control?

Yes

Do you spray herbicide (weed killers) in or around your home?

Yes

Do you use conventional insect repellants on your self or family?

Yes

Do you use conventional sunscreen?

Yes

Do you use conventional perfume or cologne every day?

Yes

Do you get your hair colored?

Yes

Do you use aerosol hairspray?

Yes

Do you get your nails done?

Yes

If so, how often?

Do you use air freshener in your house, work or car?

Yes

Do you drink filtered water?

Yes

If so, what type of filter do you have?

Do you drink bottle water?

Yes

Do you have a water filtration system for your entire house or shower filtration?

Yes

Does your spouse or other family members work around chemicals?

Yes

Can you think of any other toxic exposures you may have had?

Yes

🌿Molds

How old is the home you are living in? How long have you lived there? Have you noticed symptoms since moving in? If so, what?

Do you see mold growing in your home, work or school?

Yes

Have you ever had water damage in your home, work or school?

Yes

Does you home, workplace or school have a damp or mildew smell?

Yes

Does spending time in your basement cause or worsen your symptoms?

Yes

Does your basement ever get wet?

Yes

Do you have a crawl space?

Yes

Does you basement or crawl space have a sump pump?

Yes

Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms?

Yes

Does your car have a mildew smell?

Yes

Does anyone in your home have asthma like symptoms?

Yes

Does anyone in your family have chronic sinus infections or irritations?

Yes

✨Inflammation

Have you ever been diagnosed with Lyme Disease?

Yes

Was your mother ever diagnosed with Lyme Disease?

Yes

Do you have small joint pain?

Yes

Have you ever been bitten by a tick or recluse spider?

Yes

Have you ever seen a bulls-eyes rash appear on any part of your body?

Yes

Did the bulls-eyes rash appear shortly after following a tick, spider bits or time spent outdoors?

Yes

Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition?

Yes

Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

Yes

💖Health History

Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities?

Yes

Does anyone in your family experience similar symptoms to yours?

Yes

What is your birth order (i.e. First born, second, third, etc.)?

Do you have any history of kidney dysfunction?

Yes

Do you or any immediate family member have a history with cancer?

Yes

Do you have any history of heart disease, myocardial infarction (heart attack), etc.?

Yes

Are you currently having any thoughts of suicide?

Yes

Have you every been diagnosed with bipolar disorder, schizophrenia or depression?

Yes

Do you have a history of strokes?

Yes

Have you ever been diagnosed with diabetes, thyroiditis, or heart disease?

Yes

Have you ever been in an auto accident, fallen or received a major physical injury?

Yes

Are you in menopause?

Yes

🙏Microbiome Health

Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, brussels sprouts or other vegetables?

Yes

Do you often have gas that has a sulfur or foul smell?

Yes

Are you sensitive to supplements?

Yes

Have you ever been vegan or vegetarian for any length of time?

Yes

Option 3

Can you tolerate Meat?

Yes

Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid?

Yes

Have you taken birth control or hormone replacement therapy for any length of time?

Yes

If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving?

Yes

Have been on antibiotics for any extended period of time or often as a child or adult?

Yes

Were you caesarian delivered?

Yes

Were you breast fed?

Yes

Option 3

Does your gut temporarily feel better after a round of antibiotics?

Yes

How many times a day are you having a bowel movement?

✨Rate Symptoms

Rate each of the following symptom to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank.

0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect

1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect

Anxiety

BadGood

Mood swings

BadGood

Enraged behavior or anger for no reason

BadGood

Excessive shyness, timidity, social phobia (not typical to your personality)

BadGood

Irritability (not typical to your personality)

BadGood

Low body temperature (below 97.5)

BadGood

Insomnia (can't get to sleep or return to sleep)

BadGood

Dizziness

BadGood

Sound in ears (ringing or hearing your heart beat)

BadGood

Psychological symptoms, even thoughts of suicide

BadGood

Sensitivity to sound

BadGood

Indecisiveness feeling of being overwhelmed or fearful

BadGood

Metallic taste in your mouth

BadGood

Bad breath, Bleeding gums, Sensitive teeth

BadGood

Canker sores or other sores in the mouth

BadGood

Floaters, shadows or swimmers when you read or look into the sky

BadGood

Dyslexia or loss of place while reading, even as a child

BadGood

Swelling eyelids

BadGood

Peeling on top layer of skin (hands, feet)

BadGood

Dry skin

BadGood

Sensitivity to light

BadGood

Fatigue after exercising (feeling worse)

BadGood

Bad night vision or seeing halos around lifts

BadGood

Shortness of breath, with very little effort

BadGood

Excessive thirst and/or frequent urination

BadGood

Red eyes or tearing

BadGood

Blurred vision at times

BadGood

Morning stiffness

BadGood

Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners

BadGood

Chronic fatigue or weakness

BadGood

Non-restful sleep

BadGood

Receive static shock more often and with more dramatic effect than normal (doorknobs, car, light switch, people..)

BadGood

Trouble processing new information

BadGood

Word reversal or trouble finding words

BadGood

Sensitivity to touch

BadGood

Short-term memory loss

BadGood

Chronic Sinus congestion

BadGood

Dry non-productive cough

BadGood

Muscle twitching

BadGood

Excessive sweating, especially at night

BadGood

Heart pain (angina) and you are under 45yrs old

BadGood

Depression

BadGood

Gout (arthritic pain, especially in big toes)

BadGood

Pain in shoulders or upper back

BadGood

Twitching eyelids

BadGood

Anemia (low iron/hemoglobin on blood test)

BadGood

Wrist/ankle drop or weak extensor muscles

BadGood

Hair falls out (not normal male pattern baldness)

BadGood

Join pain-not necessarily true arthritis can move from joint to joint

BadGood

Difficulty losing weight regardless of diet or exercise

BadGood

Persistent fugal or viral infection, including athlete foot, warts, jock itch, candidiasis

BadGood

Frequent illness, prolonged illness or sick days

BadGood

Numbness or weakness in arms & legs

BadGood

Headaches

BadGood

Trouble adding or dividing numbers in your head

BadGood

Fluctuating constipation & diarrhea

BadGood

Stomach pain for no apparent reason

BadGood

Appetite swings

BadGood

Frequent muscle aches, cramps, unusual sharp sudden pains

BadGood

Rashes or Resaca

BadGood

Cold extremities (hands & feet)

BadGood

💞Thank you so much for taking the time to complete the NTA Assessment Questionnaire. I know it was a longer and more in-depth process, and I truly appreciate your commitment.

Your responses provide valuable insight and help us get closer to the root of what may be contributing to your health concerns.

Please be sure to check your email for a message with a link to schedule your next appointment, where we will review your results together.

I look forward to connecting with you soon and supporting you on your health journey.

Country Root Healing

Country Root Healing 🌿 Holistic Awakening Specialist, Certified Cellular Detoxification & Diet/Fasting Variation Coach

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