Toxicity Questionnaire - Purchase 21 day body detox diet for colon cleansing and healthy weight loss

Itchy ears

Ear aches, ear infections

Drainage from ear

Ringing in ears/hearing loss

TOXICITY QUESTIONNAIRE

FIRST: PLEASE PROVIDE US WITH YOUR CONTACT INFORMATION
* required
Name*:
Phone*:
Email*:		PLEASE BE SURE BOTH EMAIL ADDRESSES ARE CORRECT AND MATCH.
Validate Email*:
How did you hear about the program?*:
If you have not heard back from us within 24 hours, your email address may be incorrect. If this is the case, please revisit our site and resubmit this evaluation. - Thank you!
Additional Comments, Health Issues and/or Medications, if any:

The Toxicity Questionnaire is designed to aid the practitioner is assessing a client's potential need for a clinical purification program.

Section I: Symptoms

Rate each of the following symptoms based upon your health profile for the past 90-180 days.

Mark the corresponding number
0 Rarely or never experience the symptom
1 Occasionally experience the symptom	Effect not severe
2 Occasionally experience the symptom	Effect severe
3 Frequently experience the symptom	Effect not severe
4 Frequently experience the symptom	Effect severe

Section I total:

Section II: Risk of Exposure

16. Mark the corresponding number for question 16a-f below 0 never 1 rarely 2 monthly 3 weekly 4 daily

a. How often are strong chemicals used in your home?
(disinfectants, bleaches, oven & drain cleansers, furniture polish, floor wax, window cleaners, etc.)

b. How often are pesticides used in your home?

c. How often is your home treated for insects?

d. How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense or varnish in home/office?

e. How often are you exposed to nail polish, perfume, hair spray, and other cosmetics?

f. How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?

total:

17. Mark the corresponding number for question 17a-b below 0 No
change 1 Mild
change 2 Moderate change 3 Drastic change

a. Have you noticed any negative change in your health since you moved into your home or apartment?

b. Have you noticed any negative change in your health since you started your new job?

total:

18. Mark the corresponding number for question 18a-d below Yes No

a. Do you have a water purification system in your home?

b. Do you have any indoor pets?

c. Do you have an air purification system in your home?

d. Are you a dentist, painter, farm or construction worker?

total:

Grand Total Sections I + II:

Add up the numbers to arrive at the total for each section, and then add the totals for each section to arrive at the grand total. If any individual section total is 6 or more, or the grand total is 40 or more, you may benefit from a 21 Day Body Detox Diet program for body cleansing and weight loss.

1.	Digestion	0	1	2	3	4
a.	Nausea and/or vomiting
b.	Diarrhea
c.	Constipation
d.	Bloated
e.	Belching and/or passing gas
f.	Heartburn
					total:

3.	Emotions	0	1	2	3	4
a.	Mood swings
b.	Anxiety, fear, nervousness
c.	Anger, irritability
d.	Depression
e.	Sense of despair
f.	Apathy/lethargy
					total:

4.	Energy/Activity	0	1	2	3	4
a.	Fatigue/sluggishness
b.	Hyperactivity
c.	Restlessness
d.	Insomnia
e.	Startled awake at night
					total:

8.	Mind	0	1	2	3	4
a.	Poor memory
b.	Confusion
c.	Poor concentration
d.	Poor coordination
e.	Difficulty making decisions
f.	Stuttering, stammering
g.	Slurred speech
h.	Learning disabilities
					total:

9.	Mouth/throat	0	1	2	3	4
a.	Chronic coughing
b.	Gagging
c.	Frequent need to clear throat
d.	Swollen, discolored tongue, gums, lip
e.	Canker sores
					total:

10.	Nose	0	1	2	3	4
a.	Stuffy nose
b.	Sinus problems
c.	Hay fever
d.	Sneezing attacks
e.	Excessive mucous
					total:

11.	Skin	0	1	2	3	4
a.	Acne
b.	Hives, rashes, dry skin
c.	Hair loss
d.	Flushing
e.	Excessive sweating
					total:

13.	Joints/Muscles	0	1	2	3	4
a.	Pain or aches in joints
b.	Rheumatoid arthritis
c.	Osteoarthritis
d.	Stiffness, limited movement
e.	Pain or aches in muscles
f.	Recurrent back aches
g.	Feeling of weakness or tiredness
					total:

14.	Weight	0	1	2	3	4
a.	Binge eating/drinking
b.	Craving certain foods
c.	Excessive weight
d.	Compulsive eating
e.	Water retention
f.	Under weight
					total:

16.	Mark the corresponding number for question 16a-f below	0 never	1 rarely	2 monthly	3 weekly	4 daily
a.	How often are strong chemicals used in your home? (disinfectants, bleaches, oven & drain cleansers, furniture polish, floor wax, window cleaners, etc.)
b.	How often are pesticides used in your home?
c.	How often is your home treated for insects?
d.	How often are you exposed to dust, overstuffed furniture, tobacco smoke, mothballs, incense or varnish in home/office?
e.	How often are you exposed to nail polish, perfume, hair spray, and other cosmetics?
f.	How often are you exposed to diesel fumes, exhaust fumes, or gasoline fumes?
					total:

17.	Mark the corresponding number for question 17a-b below	0 No change	1 Mild change	2 Moderate change	3 Drastic change
a.	Have you noticed any negative change in your health since you moved into your home or apartment?
b.	Have you noticed any negative change in your health since you started your new job?
				total:

18.	Mark the corresponding number for question 18a-d below	Yes	No
a.	Do you have a water purification system in your home?
b.	Do you have any indoor pets?
c.	Do you have an air purification system in your home?
d.	Are you a dentist, painter, farm or construction worker?
		total:

Grand Total Sections I + II:
Add up the numbers to arrive at the total for each section, and then add the totals for each section to arrive at the grand total. If any individual section total is 6 or more, or the grand total is 40 or more, you may benefit from a 21 Day Body Detox Diet program for body cleansing and weight loss.