Detoxification Questionnaire
Name:___________________________________________________________ Date: _____/____/_____

Please read the following symptoms and rate them based on how you have been feeling over the past 30 days.
Fill in the blanks using the appropriate numbers on the key below.
KEY:0 (or leave blank) = No, 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

Liver_____ 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_____ 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___________ TOTAL

Skin____ Experience hives, cysts, boils, rashesEyes____ Dark circles around the eyes_____ 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 grayish_____ Pale complexion_____ Skin has a sour or unpleasant odor_____ 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___________ TOTALNails

Ears____ Ear infections_____ Ridged nails_____ Splitting nails_____ White spots on nails_____ Crumbling nails_____ Ear drainage or discharge_____ Itchy ears_____ Ringing in the ears___________ TOTAL___________ TOTAL

Nose____ Stuffy nose

Head____ Tension headaches at base of skull_____ Airborne allergies_____ Sinus congestion, "stuffy head", sinus infections_____ Runny or drippy nose_____ Splitting type headache_____ Dizziness_____ Faintness___________ TOTAL___________ TOTAL
1

Mouth and Throat____ Coated tongue (yellow, grayish-white or thick film)

Heart/Lungs____ Asthma_____ 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_____ 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___________ TOTAL

Mental Emotional____ Feel ‘foggy’, thinking seems slow or fuzzy

Musculoskeletal____ Pain or swelling in joints_____ Bizarre vivid or nightmarish dreams_____ Depressed_____ Worried, apprehensive, anxious_____ Nervous or agitated_____ Mentally sluggish, reduced initiative_____ Difficulty concentrating_____ Mood swings_____ Coordination is poor_____ Poor memory_____ 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___________ TOTAL

Metabolism____ Pulse speeds after eatingEnergy Levels____ Weakness_____ Night sweats_____ MSG sensitivity_____ Mood swings associated with periods (PMS)_____ Breast tenderness associated with cycle_____ Easily fatigued, sleepy during the day_____ Fatigue is persistent and extreme_____ Apathetic and lethargic_____ Tired, in spite of a good night of rest___________ TOTAL___________ TOTAL

Weight____ Crave bread or noodles

Kidney_____ Crave certain foods_____ Retaining water_____ Excessive weight_____ Urine has a strong odor_____ Pain in mid back region_____ Urine is frothy_____ Urinate infrequently___________ TOTAL___________ TOTAL

Immune System____ Frequent infections (bladder, skin, ear, chest, sinus)

Other_____ Food allergies_____ Frequent colds or flu_____ Feel worse in moldy or musty place___________ TOTAL___________ TOTAL

Please add the numbers from each section and write the total in the space provided under that section. Then add all thetotals for each section together and put that total in the space below.
GRAND TOTAL _______2