DETOX QUESTIONNAIRE
Point count
Never or almost never have the symptom (0), Occasionally have it (1), Occasionally have it, effect is severe (2), Frequently have it, effect is not severe (3), Frequently have it, effect is severe (4)
Your answer
EMOTIONS
0
1
2
3
4
Irritability
Nervousness
Mood swings
Frequent crying
Aggressive behavior
Anxiety
Fear
Confusion
Depression
Suicidal thoughts
TOTAL EMOTIONS
SKIN
0
1
2
3
4
Increased sweating, ear wax, oily skin
Skin rashes
Brown spots on hands and face
Boils
Skin tags
Acne
Eczema
Fever blisters
Warts
TOTAL SKIN
EAR, NOSE and THROAT
0
1
2
3
4
Increased salivation
Mouth ulcers
Common cold
Sinusitis
Sore throats
Ear infections
Hay fever
Loss of smell
Cough
TOTAL EAR, NOSE and THROAT
MIND and BRAIN
0
1
2
3
4
Hyperactivity
Slammering when speaking
Difficulty in concentration
Sleep disturbance
Difficulty in making decisions
Headache
Poor memory
Poor coordination
Compulsive behavior
Memory loss
TOTAL MIND and BRAIN
DIGESTIVE SYSTEM
0
1
2
3
4
Loose stool
Diarrhea
Heartburn
Constipation
Bloating
Abdominal pain
Intolerance top certain foods
Nausea or vomiting
Severe diarrhea with blood or mucous
TOTAL DIGESTIVE SYSTEM
KIDNEY
0
1
2
3
4
Increase in urination frequency and amount
Needing to get up in the night to pass urine
Urinary tract infections and cystitis
Kidney stones
Blood in the urine
TOTAL KIDNEY
JOINTS and MUSCLES
0
1
2
3
4
Feeling muscles aches or joint aches
Tendinitis
Gout
Arthritis
Fibromyalgia
TOTAL JOINTS and MUSCLES
METABOLISM
0
1
2
3
4
Feeling of coldness
Hypoglycemia
Craving certain foods
Water retention
Obesity
Cellulite
TOTAL METABOLISM
GRAND TOTAL
0
1
2
3
4
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