Detox
Detox Questionnaire
Patient Name _____________________________ Date _________________
Toxicity may be related to many other secondary health concerns. Proper assessment and a treatment plan are important to optimize one’s health.
This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to your degree of toxicity and the strength of organs related to clearing . It is not a substitute for professional medical advice from your health care provider.
For each “Yes” answer, circle the Point Score in that section.
Add your points at the end and enter in the total score.
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___ Eyes Watery or itchy eyes___ Swollen, reddened or sticky eyelids___ Blurred or tunnel vision ( does not include near or far sighted)___ Bags or dark circles under the eyes___ Ears Itchy Ears ___ Earaches, ear infections ___ Drainage from ear ___ Ringing in ears, hearing loss ___ Nose Stuffy nose___ Sinus problems___ Hay fever___ Sneezing attacks___ Excessive mucus formation___ Mouth/Throat Chronic coughing___ Gaggin, frequent need to clear throat___ Sore throat, hoarseness, loss of voice___ Canker Sores___ Swollen or discoloured tongue, gums, lips___ Skin Acne___ Hives, rashes,dry skin___ Hair loss___ Flushing, hot flashes___ Excessive sweating___ Heart Irregular or skipped beat___ Rapid or pounding heartbeat___ Chest pain___ High blood pressure___ Stroke___ Total Heart___ Lungs Chest congestion___ Asthma, bronchitis___ Shorness of breath___ Difficulty breathing___ Total Lungs___ |
Total Head___
Total Eyes___
Total Ears___
Total Nose___
Total Mouth/Throat___
Total Skin___
Total Heart___
Total Lungs___ |
Digestion
Nausea, Vomiting___ Diarrhea___ Constipation___ Bloated___ Belching___ Gas___ Heartburn___ Intestinal /Stomach Pain___ Joints/Muscles Aches/Pains in joints___ Arthritis___ Stiffness or limitation of movement___ Aches/Pains in muscles___ Easily injured___ Feeling of weakness or tiredness___ Weight Binge eating /drinking___ Craving certain foods___ Excess weight___ Compulsive eating___ Water retention___ Underweight___ Energy Fatigue/sluggishness___ Apathy/lethargy___ Hyperactivity___ Restlessness___ Mind Poor memory___ Confusion, poor comprehension___ Poor concentration___ Poor physical coordination___ Difficulty in making decisions___ Stuttering or stammering___ Slurred speech___ Learning disabilities___ Emotions Mood swings___ Anxiety, fear, nervousness___ Anger, irritability, aggression___ Depression___ Other Frequent illness___ Frequent or urgent urination___ Genital itch or discharge___ Other___ Other___ |
Total Digestion___
Total Joints/Muscles___
Total Weight___
Total Energy___
Total Mind___
Total Emotions___
Total Other___ |
If you scored:
50-100 and digestion section less than 10- Liver light
50-100 and digestion section greater than 10-Liver and Digestion
>100 and digestion section less than 10-Liver deep
>100 and digestion section greater than 10-Inflammation, Liver and Digestion
>150 Inflammation deep, Liver and Digestion
Consult with your Naturopathic Doctor to begin your personalized Detox that is right for you!
It is recommended to consult with your health care professional team.
