Detoxification Questionnaire

Gastrointestinal symptoms

Belching or gasHeartburn or acid refluxBloating or abdominal discomfort after eatingBad breathAggravated by certain foodsDiarrheaConstipationNausea or vomitingFewer than 1 bowel movement a dayStools light in color

Liver

Wine makes you sickEasily intoxicated if drinking alcoholHangovers after drinking alcoholSweat has a strong odorFeet have a strong odorSensitive to chemicalsSensitive to tobacco smokeBothered by aspartame (Nutrasweet)Chronic fatigue or FibromyalgiaFeel wired or jittery if drinking coffee

Mental Emotional

Feel "foggy", thinking seems slow or fuzzyBizarre vivid or nightmarish dreamsDepressedWorried, apprehensive, anxiousDepressedNervous or agitatedMentally sluggishDifficulty concentratingMood swingsPoor memory

Energy levels

WeaknessEasily fatigued, sleepy during the dayApathetic and energeticTired, in spite of a good night of restFeel drained after exercising

Skin

Experience hives, cysts, boils, rashesCold sores, fever blistersDry flaky skinAcneItchy skin/dermatitisDull colored skin, yellowish, pale or grayishPale complexionSkin has a sour or unpleasant odor

Muscoloskeletal

Pain or swelling in jointsMuscles become easily fatiguedMuscle aches and painsJoints are painful upon wakingNeed to use OTC pain medsJoint pain after eating certain foodsTakes long to recover after exercising

Eyes

Dark circles around the eysPuffy eyelidsBloodshot or reddened eyesWhites of eyes are yellowedEyes are watery and/or itchyInflamed eyesBlurred vision

Ears

Ear infectionsEar drainage or dischargeItchy earsRinging in the ears

Nose

Stuffy noseAirborne allergiesSInus congestion, "stuffy head", sinus infectionsPost nasal drip

Weight

Crave bread or noodlesCrave certain foodsRetaining waterExcessive weightWeight fluctuates

General Information

Please check off if you have these symptoms