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Detox Questionnaire

Using the box below fill in the form to find out whether you need to do a detox to help boost your metabolism and optimise your health.

 

frequency of occurrence
Never	Occasionally – mildly	Occasionally – severely	Regularly – mildly	Regularly – severely	Unsure
0	1	2	3	4	?

 

 

headsymptoms		eyesymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Headaches		Watery or itchy
Faintness		Swollen, red or sticky eyelids
Dizziness		Bags, dark circles under eyes
Insomnia		Blurred or tunnel vision (not due to near/far sightedness)
Total		Total

 

earsymptoms		gutsymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Itchy ears		Nausea, vomiting
Earache, ear infections		Diarrhoea, constipation
Drainage from ear		Bloating
Ringing ears / hearing loss		Belching, flatulence
		Heartburn
		Stomach pain / cramps
Total		Total

 

mouth/throatsymptoms		skinsymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Chronic coughing		Acne
Gagging, throat clearing		Dry skin, hives, rashes
Sore throat, hoarseness		Hair loss
Swollen / discoloured tongues, gums or lips		Flushing, hot flashes
Mouth ulcers		Excessive sweating
Total		Total

 

 

nosesymptoms		heartsymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Stuffy nose		Irregular beat
Sinus problems		Rapid beats
Hay fever		Chest pain
Sneezing
Excessive mucus
Total		Total

 

joint/musclesymptoms		lungsymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Joint pain		Shortness of breath
Arthritis		Chest congestion
Stiffness / limited movement		Asthma, bronchitis
Weakness or fatigue quickly		Difficulty breathing
Muscle aches / pain
Total		Total

 

 

weightissues		energysymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Binge eating/drinking		Fatigue/sluggish
Food cravings		Apathy, lethargy
Excessive weight		Hyperactivity
Water retention		Restless leg
Underweight		Jet lag
Compulsive eating
Total		Total

 

 

mindsymptoms		emotionssymptoms
symptoms	frequency of occurrence	symptoms	frequency of occurrence
Poor memory		Mood swings
Confusion		Anxiety, fear, nervousness
Poor concentration		Anger, irritability
Poor physical coordination		Aggression
Difficulty making decisions		Depression
Slurred speech
Stuttering
Total		Total

 

othersymptoms
symptoms	frequency of occurrence
Frequent illness
Frequent urination
Urinary urgency
Genital itch or discharge
Total

 

 

toxinexposure
Personal	Yes	No	Extra info
Do you open your bowels less than daily?
Do you take medication daily (inc. contraceptive pill)?
Do you, or have you ever, taken recreational drugs?
Do you have any pins, implants or new joints in your body?
Have you ever had an anaesthetic?
Do you have any mercury fillings?
Do you have any existing health conditions?
Do you dye your hair?
Do you use a fluoride containing toothpaste?
Do you sleep less than 8 hours a night?
Diet	Yes	No	Extra info
Do you take sugar or artificial sweeteners?
Do you regularly drink caffeine?
Do you eat processed food?
Do you eat fruit and vegetables without washing them?
Do you eat fried food regularly?
Do you eat take away foods regularly?
Do you eat processed meat regularly (packaged meat, chorizo, prosciutto etc)?
Do you eat margarine?
Do you eat tuna regularly?
Do you drink fizzy drinks or cordials regularly?
Do you consume alcohol regularly?
Do you grill food regularly?
Do you eat smoked food regularly – mackerel, salmon?
Lifestyle	Yes	No	Extra info
Do you suffer with stress? (whether work or personnel)
Do you exercise more than 5 times a week for more than 60 minutes?
Do you smoke? (Or have ever smoked)
Do you wear cosmetics daily?
Do you use personal hygiene products daily?
Do you swim frequently?
Have you recently suffered a traumatic experience, got divorced, changed jobs or moved house?
Environment	Yes	No	Extra info
Do you work with chemicals (paint, household, pesticides, glues – all forms)?
Do you work with new carpets?
Are you regularly exposed to exhaust fumes?
Are you regularly exposed to dust?
Are you regularly exposed to mold or a damp environment?
Do you use chemicals to clean the house?
Do you not rinse washing up liquid off when washing the dishes?
Do you regularly travel by plane?
Do you drink chlorinated tap water?
Do you have old lead water pipes at home or at work?
Do you weld or solder?
Do you use a wood or coal stove?
Do you live near a landfill site?
Are you exposed to any metals (lead or mercury)?
Have you ever been exposed to asbestos?
Total score			N/A

 

 

Finally, for how you have been feeling over the last week, please give a rating score to the following factors from 0 – 5, with 0 being very bad and 5 being very good
Your Overall Energy Levels	Any Digestive Issues: gas / bloating, cramps	Your Concentration Levels	Your Ability to sleep	Your Overall Mood

When you have your total score note it down and find out tomorrow on The Food Physio facebook page what it suggests as to whether you need to detox. Mind you, I would argue whatever your score we all need to help our bodies to clear out toxins on a regular basis because of how many we are exposed to in todays modern world. If you do choose to do a detox make sure you keep a record of the 5 scores above and repeat them at the end of the 3 week period, you’ll be amazed at how different you feel!