Articles

Pre Detox Health Questionnaire

11th January 2018 | Written by Louise Blanchfield

Please complete your details and then indicate the frequency of occurrence you may experience against each of the symptoms described in the boxes below:

your details
Name:  
Date of Birth:  
Email address:  
Occupation:  

 

 

frequency of occurrence
Never Occasionally – mildly Occasionally – severely Regularly – mildly Regularly – severely Don’t Know
0 1 2 3 4 ?

 

 

guthealth nervoussystem
symptoms frequency of

occurrence

symptoms frequency of

occurrence

Bloating       Headaches / migraines      
Burping   Mood changes      
Diarrhoea   Memory / concentration problems      
Constipation   Emotional      
Abdominal pain / indigestion   Depression  
Flatulence   Sleep problems  

 

hormonefunction allergies&immunity
symptoms frequency of

occurrence

symptoms frequency of

occurrence

Blood sugar fluctuations       Eczema      
Energy level issues   Asthma      
Cravings   Allergies      
Hypoglycaemic attacks   Coldsores      
Caffeine consumption   Colds  
Stress   Flu  

 

cardiovascularhealth skinhealth
symptoms frequency of

occurrence

symptoms frequency of

occurrence

Chest pain       Acne      
Shortness of breath   Dry skin      
Palpitations   Dandruff      
Blood pressure problems   Rashes      

 

musculoskeletalhealth lungfunction
symptoms frequency of

occurrence

symptoms frequency of

occurrence

Joint pain       Wheezing      
Joint swelling   Excess mucus      
Back / neck pain   Sinus problems      
Injuries      
Spasms or cramp      
Poor exercise recovery      
Regular exercise      

 

please answer the following in your own words:
How often do you open your bowels? Describe your stool. Is it smooth sausage shape, cracked, loose, rabbit pellets etc.  

 

your measurements
Please provide your weight and height
Your Weight   Your Height  
Please provide your waist and hip measurements
Waist Measurement   Hip Measurement  

 

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

         

 

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