Results from this questionnaire (except for personal information) will appear in the B6 Toxicity Basic Questionnaire Results section of this website.

B6 Questionnaire

Name

First

Last

Phone (optional)

May we contact you for the purpose of B6 Toxicity research?

Gender

Age Range

How did you become vitamin B6 toxic? (Check all that apply.)

Food

A Supplement

Fortified Products (Ex. energy drinks)

Did you get toxic on FOOD ALONE?

If you got toxic from ONLY FOOD were you on a high protein (usually high B6) diet?

If you got toxic from a supplement, how much were you taking daily?

If you got toxic from a supplement, how long were you taking it?

If you got toxic on a supplement, was it P5P?

If you got toxic on a supplement, what was it?

If you got toxic on a fortified product, what was it and how often did you use it?

Did you have a B6 blood test performed?

What were your B6 blood test results and the lab’s range?

Who diagnosed you?

If Other, who was it?

If PCP or Neurologist diagnosed you, will you please share their name so others can benefit from their knowledge?

B6 toxicity is Small Fiber Polyneuropathy which affects the sensory, autonomic and motor nerves. It can affect only one of these systems, a combination or all three. Please check all that apply.

Sensory neuropathy (IE: pins and needles in hands and feet)

Autonomic neuropathy (all that is automatic can be attacked IE: pulse, blood pressure, saliva, tears)

Motor neuropathy (IE: muscle weakness and muscle wasting)

We need more information about the types of neuropathy you have; Do you have:

Did you get the skin biopsy test for Small Fiber Polyneuropathy?

If you got the skin biopsy, was it positive or negative?

Do you have any autoimmune disorders and/or do you have any autoimmune markers in your blood?

Is there any other pertinent information relating to your B6 Toxicity that you would like to share?

Would you like to sign up for our newsletter?

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