I am looking forward to a large improvement when I take the questionnaire after detox.
This questionnaire identifies signs and symptoms that address the underlying cause of your G.I.-related illness (toxins, inflammation, etc...). This questionnaire is to be completed before and after the liver detox. It will help track your progress over time.
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
DIGESTIVE TRACT
___Nausea, vomiting
___Diarrhea
___Constipation
___Bloated feeling
___Belching, passing gas
___Heartburn
___Intestinal/stomach pain
____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 inflammation.
16 to 49: You have a moderate level of inflammation.
50 or higher: You have a high level of inflammation.
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