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Detox Questionnaire: take the survey below to find out if your body is in need of detoxification. Add up your scores and call our office today for further recommendations.
Rate each of the following symptoms based upon your typical health profile for:
() Past 30 days () Past 48 hours
Point Scale
0 - Never or almost never have the symptom
1 - Occasionally have it, effect is not severe
2 - Occasionally have it, effect is severe
3 - Frequently have it, effect is not severe
4 - Frequently have it, effect is severe
HEAD ________ Headaches
________ Faintness
________ Dizziness
________ Insomnia Total_______
EYES ________ Watery or itchy eyes
________ Swollen, reddened or sticky eyelids
________ Bags or dark circles under eyes
________ Blurred or tunnel vision
(does not include near or far sightedness)
Total _______
EARS ________ Itchy ears
________ Earaches, ear infections
________ Drainage from ear
________ Ringing in ears, hearing loss
Total________
NOSE ________ Stuffy nose
________ Sinus problems
________ Hay fever
________ Sneezing attacks
________ Excessive mucus formation
Total________
MOUTH/THROAT
________ Chronic coughing
________ Gagging, frequent need to clear throat
________ Sore throat, hoarseness, loss of voice
________ Swollen or discolored tongue, gums, lips
________ Canker sores
Total________
SKIN ________ Acne
________ Hives, rashes, dry skin
________ Hair loss
________ Flushing, hot flashes
________ Excessive sweating
Total________
HEART
________ Irregular or skipped heartbeat
________ Rapid or pounding heartbeat
________ Chest pain
Total________
LUNGS ________ Chest congestion
________ Asthma, bronchitis
________ Shortness of breath
________ Difficulty breathing
Total________
DIGESTIVE TRACT
________ Nausea, vomiting
________ Diarrhea
________ Constipation
________ Bloated feeling
________ Belching, passing gas
________ Heartburn
________ Intestinal/stomach pain
Total________
JOINT/MUSCLE
________ Pain or aches in joints
________ Arthritis
________ Stiffness or limitation of movement
________ Pain or aches in muscles
________ Feeling of weakness or tiredness
Total________
WEIGHT
________ Binge eating/drinking
________ Craving certain foods
________ Excessive weight
________ Compulsive eating
________ Water retention
________ Underweight
Total________
ENERGY/ACTIVITY
________ Fatigue, sluggishness
________ Apathy, lethargy
________ Hyperactivity
________ Restlessness
Total________
MIND
________ Poor memory
________ Confusion, poor comprehension
________ Poor concentration
________ Poor physical coordination
________ Difficulty in making decisions
________ Stuttering or stammering
________ Slurred speech
________ Learning disabilities
Total________
EMOTIONS
________ Mood swings
________ Anxiety, fear, nervousness
________ Anger, irritability, aggressiveness
________ Depression
Total________
OTHER
________ Frequent illness
________ Frequent or urgent urination
________ Genital itch or discharge
Total________
GRAND TOTAL________
If you scored 15 or higher, your health could benefit from a detox program.
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Nutritional Needs of the Heart
