DETOX QUESTIONNAIRE
Write down the number to the right of your answer and total
How often are you exposed to petrochemicals (found in pesticides, artificial coloring, personal care and cleaning products)?
Rarely (0) Weekly (5) Daily (10)
How often are you exposed to pesticides?
Rarely (0) Weekly (5) Daily (10)
How often are you exposed to air pollution?
Rarely (0) Weekly (2) Daily (4)
How much time do you spend in cities?
1-2 days a month (0)
1-3 days a week (1)
4-7 days a week (2)
How often do you take prescription medication or over-the-counter medication?
Rarely (0)
Once a month (2)
Once a week or more (4)
How often do you skip meals if you are not hungry?
Never (2)
Once a month (1)
Once a week (2)
How often do you eat organic food?
Never/Rarely (5)
50 percent of the time (3)
75 percent of the time or more (1)
How often do you eat canned or frozen foods?
Rarely (0)
5-7 times a week (1)
3-7 times a week (2)
How often do you drink alcohol?
Rarely (0)
Once a week (1)
Once a day or more (2)
Do you smoke cigarettes/cigars?
Yes (2) No (0)
How often do you exercise?
Less than once a week (2)
1-2 times a week (1)
3-5 times a week (3)
Do you have mercury amalgam fillings?
Yes (4) No (0)
Do you have any root canals?
Yes (3) No (0)
Do you suffer from fibromyalgia?
Yes (5) No (0)
How often do you suffer from arthritis?
Rarely/Never (0) Weekly (2) Daily (4)
Do you suffer from inflamed bowels?
Yes (2) No (0)
How often do you experience indigestion?
Rarely (0)
Once a month (1)
Once a week or more (2)
How often do you experience belching/flatulence?
Rarely (0) Weekly (1) Daily (2)
How often do you experience diarrhea?
Rarely (0) Weekly (2) Daily (5)
Do you suffer from anemia?
Yes (3) No (0)
Do you suffer from hepatitis or other liver diseases?
Yes (10) No (0)
Do you suffer from gallbladder disease?
Yes (2) No (0)
How often do you have dry, tired eyes?
Rarely (0) Weekly (1) Daily (2)
How often do you have bags under your eyes?
Rarely (0) Weekly (1) Daily (2)
How often do you have circles under your eyes?
Rarely (0) Weekly (1) Daily (2)
How often do you have headaches?
Rarely (0) Weekly (1) Daily (2)
Do you suffer from chemical sensitivities?
Yes (5) No (0)
Do you suffer from frequent infections?
Yes (5) No (0)
Do you have chronic fatigue syndrome?
Yes (7) No (0)
Do you suffer from autoimmune disease?
Yes (10) No (0)
Do you have or have you had cancer?
Yes (10) No (0)
Do you suffer from allergies?
Yes (3) No (0)
How often do you suffer from sinus problems?
Rarely (0) Weekly (2) Daily (4)
How often do you suffer from a swollen, red tongue?
Rarely (0) Weekly (1) Daily (2)
How often do you feel apathetic?
Rarely (0) Weekly (1) Daily (2)
How wold you rate your energy level?
High (0) Moderate (2) Low (5)
How would you rate your mental acuity?
High (0) Moderate (2) Low (5)
How often do you notice that you have poor concentration?
Rarely (0) Weekly (2) Daily (5)
Do you have a poor memory?
Yes (5) No (0)
How often do you suffer from drowsiness?
Rarely (0) Weekly (1) Daily (2)
How often do you get angry or irritable?
Rarely (0) Weekly (1) Daily (2)
How often do you have mood swings?
Rarely (0) Weekly (2) Daily (5)
How often do you feel depressed?
Rarely (0) Weekly (2) Daily (5)
How often do you suffer from insomnia?
Rarely (0) Weekly (1) Daily (2)
How often do you feel groggy upon waking?
Rarely (0) Weekly (2) Daily (5)
How often do you feel that it difficult to relax?
Rarely (0) Weekly (1) Daily (2)
How often do you suffer from excessive stress?
Rarely (0) Weekly (3) Daily (5)
Score of 101 or more: Your lifestyle predisposes you to toxic buildup in your system. You are also showing elevated symptoms and risk factors for toxic accumulation. It is recommended that you reassess your lifestyle and start with a personalize assessment detox plan.