Detoxification Questionnaire
Detoxification Questionnaire
Read the following questions and rate them based on how you have been feeling in the past 30 days.
Fill in the number that applies on the form below:
KEY: 0 (or leave blank) = No or 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
Head
_____ Tension headaches at base of skull
_____ Splitting type headache
_____ Dizziness
_____ Faintness
___________ 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 gray
_____ 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
Immune System
_____ Frequent infections (bladder, skin, ear, chest, sinus)
_____ Frequent colds or flu
___________ 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 spacey, thinking seems slow or fuzzy
_____ Peculiar, vivid, or nightmarish dreams
_____ Depressed
_____ Worried, apprehensive, anxious
_____ Nervous or agitated
_____ Mentally 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 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, even after a good nights 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
Other
_____ Food allergies
_____ Feel worse in moldy or musty place
___________ TOTAL
Add the numbers from each section and write the total in the spaces provided, then add all the totals for each section together and put that total in the space below.
GRAND TOTAL _______
Interpretation
15 or less = Low toxicity
16 to 30 = Minimal toxicity
31 to 40 = Marginal toxicity
41 to 50 = High toxicity
51 or greater = Very high toxicity
Using Detoxification Techniques to Prevent Chronic Disease
Environmental chemicals, pesticides, plastics, and processed foods are some of the toxins that constantly bombard our bodies. If we do not find a way to detoxify some of these chemicals and pollutants we will become more prone to chronic disease. Most of the chronic health challenges we see today such as allergies, chronic fatigue, fibromyalgia and coronary artery disease are associated with exposure to toxins. On a regular basis we change the oil our cars and clean air filters in our furnace since we know they will run more efficiently when they are clean. We also brush our teeth and take a shower daily so that our outside of our body gets clean. The inside of our body also needs to be clean. What we eat, drink and breathe on a daily basis affects our internal organs. When we take in too many toxins, our liver has problems processing them, and soon we can have a variety of symptoms.
Here is a list of Common Symptoms of Chemicals and Toxins in the System:
1. Headaches
2. Skin Problems
3. Bad breath
4. Body odor
5. Blood sugar imbalances
6. Depression
7. Mental dullness / poor memory
8. Chronic fatigue
9. Bloating or gas
10. Poor digestion
11. Weight gain
12. Constipation
13. Premature aging and wrinkling
14. Muscle and/or joint pain
15. Unusual responses to medication and supplements
16. Insomnia
17. Hair falling out
18. Age spots
19. Water retention
20. Multiple chemical sensitivities
If you have any of the above symptoms on a regular basis, consider doing a detoxification program. Even though we take good supplements or try to eat a good diet daily, if toxins are in our system and cannot get removed effectively, many of the symptoms will become chronic. The liver is our major detoxification organ. It has a two-phase toxin removal system. In Phase I, the liver works with the intestines to help transform fat-soluble toxins into molecules that are ready to be removed from the system. In Phase II the liver attaches the toxin to a water-soluble molecule so that it can quickly be eliminated through the kidneys. This removal of the new water-soluble molecule should happen as soon as possible so that the toxins are not stored too long.
During a detoxification program it is very important to get high quality nutrition daily in an easy to absorb form. To maintain a healthy metabolism and avoid muscle wasting during detoxification, a program that incorporates bioavailable proteins, carbohydrates, fats and fiber are necessary. High quality proteins that contain the amino acids methionine and cysteine help reduce excessive fatty build-up in the liver, and support liver phase II detoxification. High quality detoxification supplements contain this lipotrophic blend of amino acids that are specifically designed to help in liver cleansing.
Carbohydrates in the form of vegetables assist in detoxifying the liver and intestines. Vegetables contain phytochemicals that assist in both phase I and phase II liver detoxification. Broccoli has indole-3- carbinols that support liver phase I and glucosinolates that support liver phase II detoxification. Fiber in the diet helps to reduce toxins even before they get absorb by the body.
