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Detox Questionnaire

4th January 2018 | Written by Louise Blanchfield

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!

 

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