PRE-DETOX QUESTIONNAIRE

DO YOU CONSISTENTLY STRUGGLE WITH THESE SYMPTOMS?

Answer YES or No. A Maybe is a YES.

1. Energy Levels
2. Sugar and Carb Cravings *
3. Sleep Quality *
4. Bowel Movement Regularity
5. Mood
6. Productivity *
7. Clarity of Thought *
8. Hunger *
9. Motivation *
10. Skin-Acne, Rashes, Rosacea *
11. Gas, Bloating, Gut Issues *
12. Sensitivity to Smell *
13. Joint Pain *
14. Headaches *
15. Difficulty Losing Weight
FIND YOUR DETOXIFICATION ABILITY SCORE
please check the appropriate response and add up your total detoxification ability score.
1. Bowel Movements
2. Sweating *
3. Water Intake *
4. Fiber Intake *
5. Digestion ( Gass, Bloating, Indigestion) *
6. Non-starchy Vegetable Specially Dark Leafy Green And Bright Colored *
7. Exercise *
8. Sulfur Rich Foods (E.g Cabbage, Broccoli, Brussel Sprouts, Eggs, Onions ) *
9. Supplements ( Vitamins, Minerals, Antioxidants) *
10. Probiotic Rich Foods & Supplements *
A = 1 Point = Poor / B=2 Points = Average / C= 3 Points = Great
Toxic Load Test
please check the appropriate response and add up your total detoxification ability score.
1. Alcohol *
2. Caffeine *
3. Chemicals *
4. Food *
5. Sugar And Processed Foods, And Artificial Sweeteners/colorings *
6. Cooking *
7. Smoking *
8. Vaccines *
9. Silver Fillings *
10. Emotional *
A= 1 Point = Low / B= 2 Points = Average / C= 3 Points = High
Name *
Name
Phone
Phone