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Detoxification Questionnaire
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Read
the following questions and rate them based on how you have been feeling in
the past 30 days.
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Type
in the best number that applies for each symptom
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KEY:
0 (Or leave blank) = No or never or almost never occurs
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1
= Occasionally occurs, effect is not severe
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2
= Occasionally occurs, effect is severe
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3
= Frequently occurs, effect is not severe
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4
= Frequently occurs, effect is severe
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Gastrointestinal
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Belching or gas
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Heartburn or acid reflux
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Bloating or abdominal
discomfort shortly after eating
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Bad breath (halitosis)
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Aggravated by certain
foods
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Diarrhea, chronic
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Undigested food in stool
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Constipation
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Nausea or vomiting
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Fewer than one bowel
movement a day
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Stools are loose and unformed
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TOTAL
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Liver
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Wine makes you sick
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Easily intoxicated if
drinking alcohol
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Hangovers after drinking
alcohol
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Sensitive to chemicals
(perfume, solvents, exhaust)
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Sensitive to tobacco
smoke
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Hemorrhoids or varicose
veins
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Bothered by aspartame
(NutraSweet)
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Chronic fatigue or
Fibromyalgia
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Feeling wired or jittery
if drinking coffee
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Feet have a strong odor
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Sweat has a strong odor
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TOTAL
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Head
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Tension headaches at base
of skull
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Splitting type headache
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Dizziness
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Faintness
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TOTAL
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Skin
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Experience hives, cysts,
boils, rashes
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Cold sores, fever
blisters, or herpes lesions
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Dry flaky skin and/or
dandruff
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Fragile skin, easily
chaffed, as in shaving
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Acne
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Itchy skin / dermatitis
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Dull colored skin,
yellowish, pale or gray
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Pale complexion
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Skin has a sour or
unpleasant odor
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TOTAL
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Eyes
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Dark circles around the
eyes
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Puffy eyelids
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Bags under the eyes
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Bloodshot or reddened
eyes
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Whites of eyes are
yellowed
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Inflamed eyelids
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Eyes are water and/or
itchy
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Blurred or tunnel vision
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TOTAL
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Nails
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Ridged nails
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Splitting nails
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White spots on nails
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Crumbling nails
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TOTAL
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Ears
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Ear infections
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Ear drainage or discharge
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Itchy ears
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Ringing in the ears
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TOTAL
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Nose
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Stuffy nose
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Airborne allergies
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Sinus congestion,
"stuffy head", sinus infections
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Runny or drippy nose
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TOTAL
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Immune
System
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Frequent infections
(bladder, skin, ear, chest, sinus)
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Frequent colds or flu
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Food allergies
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Feel worse in moldy or
musty place
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TOTAL
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Mouth
and Throat
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Coated tongue (yellow,
grayish-white or thick film)
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Swollen tongue
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Hoarseness
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Difficulty swallowing
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Lump in throat
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Dry mouth, eyes and / or
nose
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Gag easily or need to
clear throat often
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Mouth ulcers or canker
sores
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TOTAL
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Heart/Lungs
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Asthma
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Wheezing or difficulty
breathing
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Shortness of breath
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Chest congestion
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Heart races, rapid
heartbeat
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Fast pulse at rest
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Flush or blush easily or
face turns red for no reason
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Heart skips beats
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TOTAL
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Mental
Emotional
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Feel spacey, thinking
seems slow or fuzzy
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Peculiar, vivid, or
nightmarish dreams
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Depressed
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Worried, apprehensive,
anxious
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Nervous or agitated
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Mentally sluggish,
reduced initiative
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Difficulty concentrating
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Mood swings
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Coordination is poor
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Poor memory
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TOTAL
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Musculoskeletal
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Pain or swelling in
joints
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Muscles become easily
fatigued
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Muscle aches and pains
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Arthritic tendencies
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Joints are painful upon
waking
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Joint pain after mild
exertion
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Joint pain experienced
after eating certain foods
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Abdomen tends to hang out
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Surface of abdomen is
uneven and distended
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Use over-the-counter pain
medications
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TOTAL
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Metabolism
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Pulse speeds after eating
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Night sweats
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MSG sensitivity
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Mood swings with periods
(PMS)
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Breast tenderness
associated with cycle
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TOTAL
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Energy
Levels
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Weakness
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Easily fatigued, sleepy
during the day
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Fatigue is persistent and
extreme
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Apathetic and lethargic
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Tired, even after a good
nights rest
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TOTAL
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Weight
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Crave bread or noodles
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Crave certain foods
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Retaining water
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Excessive weight
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TOTAL
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Kidney
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Urine has a strong odor
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Pain in mid back region
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Urine is frothy
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Urinate infrequently
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TOTAL
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Check
to see which areas have the highest totals.
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Then
add them all together to get the Grand Total
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GRAND TOTAL
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Interpretation
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15
or less = Low toxicity
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16
to 30 = Minimal toxicity
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31
to 40 = Marginal toxicity
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41
to 50 = High toxicity
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51
or greater = Very high toxicity
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