Detoxification Health Quiz
Rate each of the following symptoms based on your typical health profile for the PAST 30 DAYS

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
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Headaches
Faintness
Dizziness
Insomnia
Subtotal of Headaches/Faintness/Dizziness/Insomnia:
Watery or Itchy Eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Subtotal of watery or itchy eyes/swollen,reddened or sticky eyelids/Bags or dark circles under eyes/Blurred or tunnel vision
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Subtotal: Itchy ears/Earaches, ear infections/Drainage from ear/Ringing in ears, hearing loss
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Subtotal: Stuffy nose/Sinus problems/Hay fever/Sneezing attacks/Excessive mucus formation
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Subtotal: Chronic coughing/Gagging, frequent need to clear throat/Sore throat, hoarseness, loss of voice/Swollen or discolored tongue, gums, lips/Canker sores
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating
Subtotal: Acne/Hives, rashes, dry skin/Hair loss, Flushing, hot flashes/Excessive sweating
Chest pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Subtotal: Chest pain/Irregular or skipped heartbeat/Rapid or pounding heartbeat
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Subtotal: Chest congestion/Asthma, bronchitis/Shortness of breath/Difficulty breathing
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intstestinal/stomach pain
Subtotal: Nausea, vomiting/Diarrhea/Constipation/Bloated feeling/Belching, passing gas/Heartburn/Intestinal-stomach pain
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles
Subtotal: Pain or aches in joints/Arthritis/Stiffness or limitation of movement/Feeling of weakness or tiredness/Pain or aches in muscles
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating
Subtotal: Binge eating-drinking/Craving certain foods/Excessive weight/Water retention/Underweight/Compulsive eating
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Subtotal: Fatigue, sluggishness/Apathy, lethargy/Hyperactivity/Restlessness
Poor memory
Confusion, poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination
Subtotal: Poor memory/Confusion, poor comprehension/Difficulty in making decisions/Stuttering or stammering/Slurred speech/learning disabilities/Poor concentration/Poor physical coordination
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Subtotal: Mood swings/Anxiety, fear, nervousness/Anger, irritability, aggressiveness/Depression
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Subtotal: Frequent illness/Frequent or urgent urination/Genital itch or discharge
Grand Total *
How Old Are You?
(anonymous and optional)
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In your own words, What's the biggest thing stopping you from starting a new weight loss plan?
(anonymous and optional)
Imagine you reached your optimum weight in the next 3 months. What changes would you hope to notice in your life?
(anonymous and optional)
Scoring
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