Biotoxin Symptom Cluster Screener
Based on Dr. Ritchie Shoemaker's published symptom-cluster methodology for Chronic Inflammatory Response Syndrome (CIRS). Select every symptom you are currently experiencing. Eight or more positive clusters out of 13 is the threshold used in Shoemaker's case definition.
Why this matters
CIRS (Chronic Inflammatory Response Syndrome) is a biotoxin-driven inflammatory illness most commonly triggered by exposure to water-damaged buildings, but also seen with tick-borne illness, ciguatera, and a handful of other biotoxin sources. The symptom pattern is wide-spectrum and crosses organ systems, which is exactly why it tends to get missed by single-specialty workups.
The Shoemaker symptom-cluster screen is the fastest way to identify the multi-system pattern. A count at or above 8 of 13 is the symptom-cluster criterion in his published case definition; below that, the screen does not rule biotoxin illness out, but it lowers the probability.
The three result tiers
- < 6Low likelihood. Pattern not strongly suggestive of biotoxin-driven illness, though many symptoms are non-specific.
- 6–7Subthreshold. Close to the case-definition cutoff; targeted CIRS biomarker testing is reasonable.
- ≥ 8Shoemaker-positive. Meets the symptom-cluster criterion. Full workup should include exposure history, biomarkers, and exclusion of alternatives.
A high cluster count does not confirm CIRS. The symptom screen is one of three Shoemaker criteria, alongside documented biotoxin exposure and supportive biomarker testing.
A screen is the start, a proper evaluation is the answer.
A full Asymmetric Health workup pairs Shoemaker's CIRS biomarkers (VCS, C4a, TGF-β1, MSH, VEGF, MMP-9, HLA-DR) with broader hormonal, mitochondrial, and inflammatory testing, so any biotoxin treatment plan is built around your full physiology, not the symptom screen alone.
About the CIRS screener
What is CIRS?
CIRS (Chronic Inflammatory Response Syndrome) is a biotoxin-driven inflammatory illness most commonly associated with exposure to water-damaged buildings (mold, mycotoxins, bacteria, actinomycetes). It can also be triggered by tick-borne illness, ciguatera fish poisoning, dinoflagellates, and other biotoxin sources. Genetically susceptible individuals (roughly 24% of the population by HLA-DR genotype) are unable to mount an effective antibody response, leading to a sustained inflammatory cascade.
How does this screener work?
The screener uses Dr. Ritchie Shoemaker's published 13-cluster symptom framework. The 35 symptoms shown map to 13 organ-system clusters; a cluster is "positive" when at least one of its symptoms is endorsed. The score is the count of positive clusters out of 13. Shoemaker's case definition uses ≥ 8 of 13 as the symptom-cluster criterion.
What does it mean if I score 8 or higher?
A score at or above 8 meets the symptom-cluster criterion in the published Shoemaker case definition. The full diagnosis additionally requires documented or plausible biotoxin exposure (most commonly a water-damaged building), supportive biomarkers (visual contrast sensitivity testing plus serum C4a, TGF-β1, MSH, MMP-9, VEGF, and HLA-DR genotype), and exclusion of alternative diagnoses. A free consultation can map the right next step.
I scored below 8. Does that rule CIRS out?
No. A subthreshold score reduces but does not exclude biotoxin-driven illness. Many of the symptoms are also non-specific and can reflect other infectious, autoimmune, endocrine, neurologic, or psychiatric conditions. If exposure history is significant or symptoms persist, targeted biomarker testing and a broader functional workup can still be worthwhile.
Why does the screener not show me the cluster groupings?
The cluster groupings are clinician-facing. Showing them upfront tends to bias responses, since people unconsciously check related symptoms together once they see a category label. The flat presentation produces a more honest symptom inventory. The PDF report does break the results out by cluster.
Is this a diagnostic test?
No. The cluster screen is one component of a full CIRS evaluation. Diagnosis additionally requires documented exposure, biomarker testing, and clinical interpretation in context. A high cluster count does not confirm CIRS, and a low count does not rule it out.
Evidence & Sources
- Shoemaker RC, House D, Van Kampen V. A novel treatment protocol for biotoxin-associated illness arising from exposure to water-damaged buildings. Health. 2013;5(3):396–401.
- Shoemaker RC, House DE. Sick building syndrome (SBS) and exposure to water-damaged buildings: time series study, clinical trial and mechanisms. Neurotoxicol Teratol. 2006;28(5):573–588. doi:10.1016/j.ntt.2006.07.003
- Shoemaker RC. Surviving Mold: Life in the Era of Dangerous Buildings. Otter Bay Books; 2010.
- Shoemaker RC, Mark L, McMahon S, Thrasher JD, Grimes C. Research Committee Report on Diagnosis and Treatment of Chronic Inflammatory Response Syndrome Caused by Exposure to the Interior Environment of Water-Damaged Buildings. 2010.
Clinical Disclaimer: The Shoemaker symptom-cluster screen is one component of a full CIRS evaluation. Diagnosis additionally requires documented biotoxin exposure, supportive biomarkers (e.g., visual contrast sensitivity, C4a, TGF-β1, MSH, MMP-9, VEGF, HLA-DR), and exclusion of confounding diagnoses. A high cluster count does not confirm CIRS, and a low count does not rule it out. Many of these symptoms are non-specific and may reflect other conditions. Always interpret in the context of a complete clinical evaluation.