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.
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
___Ringing in ears/ loss of hearing
___Earaches/ ear infections
___Drainage from ear
___Bags or dark circles under eyes
___Watery or itchy eyes
___Swollen, reddened, or sticky eyelids
___Blurred or tunnel vision (excluding near- or far- sightedness)
___Sinus congestion, sinus infection
___Excess mucus formation
___Sore throat, hoarseness, loss of voice
___Gagging, frequent need to clear throat
___Swollen tongue, gums, or lips
___Swollen lymph nodes
___Canker sores, mouth ulcers
___Irregular or skipped heartbeat
___Rapid or pounding heartbeat
___Shortness of breath
___Acne or brown “age/liver spots”
___Hives, rashes, cysts, boils
___Eczema or psoriasis
___Hair loss, hair thinning
___Pain or aches in joints or lower back
___Stiffness or limitation of movement
___Pain or aches in muscles
___Anxiety, fear, or nervousness
___Anger, irritability, or aggressiveness
___Feeling of weakness
___Difficulty losing weight
___Crave certain foods
___Frequent colds, flus
___Chemical or environmental sensitivities
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.
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.