Disclaimer

You must read this completely then check off on all conditions in order to use the survey.

The Neurotoxicity Screening Survey (NSS) is designed as an educational tool to help you and your doctor understand your health condition. Dr. Raymond Singer, Ph.D., routinely uses the NSS in his practice as a neuropsychologist and neurotoxicologist to assist his diagnostic procedures. Dr. Singer recommends that the results be used by your doctor to help him reach a diagnosis and design a treatment program for you.

The NSS is not a medical test, and it is not recommended that a person or a doctor rely upon this survey alone to diagnose or prove any illnesses (neurotoxic, neuropsychological or medical illnesses). The symptoms must be interpreted in the context of the person's history.

If your doctor is not experienced in neuropsychology and neurotoxicology, he can consult with other specialists with that experience to assist him in his diagnostic processes. For example, Dr. Raymond Singer has been studying neuropsychology and neurotoxicology since 1979.

The norms used to analyze the NSS are applicable to the age range of 18-65 years. If the NSS is administered to people younger than 18 or older than 65, the results are advisory only. Please consult your doctor for further advice.

Results of the NSS are not guaranteed. No refunds are available. For any persisting symptoms (medical, psychological, neuropsychological, etc.), see your personal doctor for diagnosis and treatment.

Check each box after reading:

I have read this disclaimer

I understand what it says.

I will not hold Dr. Raymond Singer - nor any company or organization with which Dr. Singer is associated - liable for any damages that may result from my use of the NSS.

Registration Information:

* First Name

* Last Name

* Street:

Street:

* City:

* State:

* Zip:

Phone:

* Your Email

Referral Code:


Memory

* Were you exposed at less than 3 years of age?:

* Can you remember how you were functioning before you were exposed?:

* Have you completed the Neurotoxicology Screening Survey before?:


Census

* Your Age:

* Education:

Location this survey was completed:

Did anyone help you complete this form?:

What type of help?:

Referred to Dr. Singer by:

Doctor's name (if any):


Environment

* Ethnicity:

Ethnicity if Other:

* Gender:

Current Residence:


Exposure

* Chemical(s) / toxic agents to which you think you were exposed:

Exposure begin date:

Exposure end date:

Current Occupation:

Most senior or highest title at work: