Should You Detox? Take the Quiz

Detoxification Questionnaire

Name:_____________________________ _____________________________

Date: _____/____/_____

Please read the following symptoms and rate them based on how you have been feeling over the past 30 days.

Fill in the blanks using the appropriate numbers on the key.


0 (or leave blank) = No, 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


____ 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


_____ 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


____ 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 grayish

_____ Pale complexion

_____ Skin has a sour or unpleasant odor

___________ TOTAL


____ 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


_____ Ridged nails

_____ Splitting nails

_____ White spots on nails

_____ Crumbling nails

___________ TOTAL


____ Ear infections

_____ Ear drainage or discharge

_____ Itchy ears

_____ Ringing in the ears

___________ TOTAL


____ Stuffy nose

_____ Airborne allergies

_____ Sinus congestion, “stuffy head”, sinus infections

_____ Runny or drippy nose

___________ TOTAL


____ Tension headaches at base of skull

_____ Splitting type headache

_____ Dizziness

_____ Faintness

___________ 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


____ 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 ‘foggy’, thinking seems slow or fuzzy

_____ Bizrre vivid or nightmarish dreams

_____ Deprssed

_____ Wrried, apprehensive, anxious

_____ Nrvous or agitated

_____ entally sluggish, reduced initiative

_____ Difficulty concentrating

_____ Mood swings

_____ Coordination is poor

_____ Poor memory

___________ TOTAL


____ 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


____ Pulse speeds after eating

_____ Night sweats

_____ MSG sensitivity

_____ Mood swings associated 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, in spite of a good night of rest

___________ TOTAL


____ Crave bread or noodles

_____ Crave certain foods

_____ Retaining water

_____ Excessive weight

___________ TOTAL


_____ Urine has a strong odor

_____ Pain in mid back region

_____ Urine is frothy

_____ Urinate infrequently

___________ TOTAL

Immune System

____ Frequent infections (bladder, skin, ear, chest, sinus)

_____ Frequent colds or flu

___________ TOTAL


_____ Food allergies

_____ Feel worse in moldy or musty place

___________ TOTAL

Please add the numbers from each section and write the total in the space provided under that section. Then add all the

totals for each section together and put that total in the space below.