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The 7 Day Detox Kit
The Detox Kit               

Are you Toxic?
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How Toxic Are You?
How Toxic Are You??

How Toxic Are You??

DETOXIFICATION QUESTIONNAIRE- GENERAL SIGNS & SYMPTOMS

Patient Name: _________________________  Date: ___________

This questionnaire gives your healthcare provider an indication of your toxicity level based on common signs and symptoms related to toxicity. It will also provide information to see if you have less toxic signs and symptoms after the 7-day Restore Core BT detoxification program. Please complete this questionnaire before and after the 7-day Restore Core BT detoxification program.    


Point Scale:
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe 
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
 
HEAD
___Headaches
___Dizziness
___Insomnia
___Faintness

____TOTAL
 
EARS
___Itchy ears
___Ringing in ears/ loss of hearing
___Earaches/ ear infections
___Drainage from ear

____TOTAL
 
EYES
___Bags or dark circles under eyes
___Watery or itchy eyes
___Swollen, reddened, or sticky eyelids
___Blurred or tunnel vision (excluding near- or far- sightedness)

____TOTAL
 
NOSE
___Stuffy nose
___Sinus congestion, sinus infection
___Constant sneezing
___Hay fever/allergies
___Excess mucus formation

____TOTAL
 
MOUTH/THROAT
___Chronic coughing
___Sore throat, hoarseness, loss of voice
___Gagging, frequent need to clear throat
___Swollen tongue, gums, or lips
___Swollen lymph nodes
__­_Canker sores, mouth ulcers

____TOTAL
 
HEART
___Chest pain
___Irregular or skipped heartbeat
___Rapid or pounding heartbeat

____TOTAL
 
LUNGS
___Asthma, bronchitis
___Chest congestion
___Shortness of breath
___Difficulty breathing

____TOTAL
 
SKIN
___Acne or brown “age/liver spots”
___Hives, rashes, cysts, boils
___Eczema or psoriasis
___Itchy skin/dermatitis
___Hair loss, hair thinning
___Body odor
___Excessive sweating

____TOTAL
 
JOINTS/MUSCLES
___Pain or aches in joints or lower back
___Stiffness or limitation of movement
___Arthritis
___Pain or aches in muscles

____TOTAL
 
MENTAL/EMOTIONAL
___Poor memory
___Difficulty concentrating
___Mood swings
___Depression
___Anxiety, fear, or nervousness
___Anger, irritability, or aggressiveness
___Insomnia

____TOTAL
 
ENERGY LEVEL
___Fatigue/low energy
___Restlessness
___Hyperactivity
___Feeling of weakness

____TOTAL
 
WEIGHT
___Underweight
___Overweight
___Difficulty losing weight
___Crave certain foods

____TOTAL
 
 OTHER
___PMS
___Frequent colds, flus
___Chemical or environmental sensitivities
___Food allergies/sensitivities

____TOTAL
 
Please add the numbers from each section and write the section total in the spaces provided, then add all the section totals together and put that total in the space below.
 
____GRAND TOTAL
 
 
Interpreting Your GRAND TOTAL Toxicity Score:
 
15 or lower: You have a low level of toxicity.
16 to 49: You have a moderate level of toxicity.
50 or higher: You have a high level of toxicity.
200 S. Courtland Street # 623, East Stroudsburg, PA 18301

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