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