Should You Detox? Take the Quiz
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.
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
_____ 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
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 grayish
_____ 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
Head
____ Tension headaches at base of skull
_____ Splitting type headache
_____ Dizziness
_____ Faintness
___________ 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 ‘foggy’, thinking seems slow or fuzzy
_____ Bizrre vivid or nightmarish dreams
_____ Deprssed
_____ Wrried, apprehensive, anxious
_____ Nrvous or agitated
_____ entally 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 associated 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, in spite of a good night of 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
Immune System
____ Frequent infections (bladder, skin, ear, chest, sinus)
_____ Frequent colds or flu
___________ TOTAL
Other
_____ Food allergies
_____ Feel worse in moldy or musty place
___________ TOTAL
Please add the numbers from each section and write the total in the space provided under that section. Then add all the
totals for each section together and put that total in the space below.
GRAND TOTAL _______