The Toxicity & Symptom Screening Questionnaire

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

  1. 0  = Never or almost never have the symptom

  2. 1  = Occasionally have it, effect is not severe

  3. 2  = Occasionally have it, effect is severe

  4. 3  = Frequently have it, effect is not severe

  5. 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....