The Toxicity & Symptom Screening Questionnaire

This questionnaire identifies symptoms that help to identify the underlying causes of illness and helps you track your progress over time. Rate each of the following symptoms based on your health over the past 30 days. If you are filling out this questionnaire after the first two days of detox, record your symptoms for the last 48 hours ONLY.

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

DIGESTIVE TRACT

____ Nausea or vomiting
____ diarrhea
____ Constipation
____ Bloated feeling
____ Belching, or passing gas
____ Heartburn
____ intestinal/stomach pain

total ________

EARS

____ itchy ears
____ earaches, ear infections
____ drainage from ear
____ ringing in ears, hearing loss

total ________

EMOTIONS ____ Mood swings ____ anxiety, fear, or nervousness ____ anger, irritability, or aggressiveness ____ depression total ________	JOINTS / MUSCLES ____ Pain or aches in joints ____ arthritis ____ stiffness or limitation of movement ____ Pain or aching in muscles ____ Feeling of weakness or tiredness total ________
energy/acTiviTy ____ Fatigue, sluggishness ____ apathy, lethargy ____ Hyperactivity ____ restlessness total ________
	LUNGS ____ Chest congestion ____ asthma, bronchitis ____ shortness of breath ____ difficult breathing total ________
EYES ____ Watery or itchy eyes ____ swollen, reddened, or sticky eyelids ____ Bags or dark circles under eyes ____ Blurred or tunnel vision (does not include near- or far-sightedness) total ________
	MIND ____ Poor memory ____ Confusion, poor comprehension ____ Poor concentration ____ Poor physical coordination ____ difficulty in making decisions ____ stuttering or stammering ____ slurred speech ____ learning disabilities total ________
HEAD ____ Headaches ____ Faintness ____ dizziness ____ insomnia total ________
	MOUTH / THROAT ____ Chronic coughing ____ Gagging, frequent need to clear throat ____ sore throat, hoarseness, loss of voice ____ swollen or discolored tongue, gum, lips ____ Canker sores total ________
HEART ____ irregular or skipped heartbeat ____ rapid or pounding heartbeat ____ Chest pain total ________

NOSE ____ stuffy nose ____ sinus problems ____ Hay fever ____ sneezing attacks ____ excessive mucus formation total ________	WEIGHT ____ Binge eating/drinking ____ Craving certain foods ____ excessive weight ____ Compulsive eating ____ Water retention ____ underweight total ________
SKIN ____ acne ____ Hives, rashes, or dry skin ____ Hair loss ____ Flushing or hot flushes ____ excessive sweating total ________
	OTHER ____ Frequent illness ____ Frequent or urgent urination ____ Genital itch or discharge total ________

GRAND TOTAL: ______________

KEY TO QUESTIONNAIRE

1. add individual scores and total each group.

2. add each group score for a grand total.

Optimal - is less than 10

Mild toxicity - 10−50

Moderate toxicity - 50−100

Severe toxicity - over 100

Now let's get you on the right track....

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