Detoxification Survey

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* 1. Please take a few moments to complete our Detoxification Survey. When your questionnaire is complete, a Health Renewal doctor will evaluate your answers. Please tick the box below if you agree that a Health Renewal doctor can call you to discuss your score?

I agree

I do not agree

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* 2. What is your Name and Surname?

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* 3. Which Renewal Institute branch is your home branch?

Brooklyn

Bedfordview

Claremont

Cape Quarter

Constantia

Fourways

Durban

Hillcrest

Irene

Illovo

Morningside

Parkhurst

Stellenbosch

Umhlanga

West Rand

Willowbridge

If you are not a client, please supply your email address below?

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* 4. Please select your Gender?

Male

Female

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* 5. Section A: Medical Symptoms Questionnaire:

Please rate each of the following symptoms based on your typical health profile for the past month.
Points 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

	0	1	2	3	4
Headaches	Headaches 0	Headaches 1	Headaches 2	Headaches 3	Headaches 4
Faintness	Faintness 0	Faintness 1	Faintness 2	Faintness 3	Faintness 4
Dizziness	Dizziness 0	Dizziness 1	Dizziness 2	Dizziness 3	Dizziness 4
Insomnia	Insomnia 0	Insomnia 1	Insomnia 2	Insomnia 3	Insomnia 4
Watery or itchy eyes	Watery or itchy eyes 0	Watery or itchy eyes 1	Watery or itchy eyes 2	Watery or itchy eyes 3	Watery or itchy eyes 4
Swollen, reddened or sticky eyelids	Swollen, reddened or sticky eyelids 0	Swollen, reddened or sticky eyelids 1	Swollen, reddened or sticky eyelids 2	Swollen, reddened or sticky eyelids 3	Swollen, reddened or sticky eyelids 4
Bags or dark circles under eyes	Bags or dark circles under eyes 0	Bags or dark circles under eyes 1	Bags or dark circles under eyes 2	Bags or dark circles under eyes 3	Bags or dark circles under eyes 4
Blurred or tunnel vision	Blurred or tunnel vision 0	Blurred or tunnel vision 1	Blurred or tunnel vision 2	Blurred or tunnel vision 3	Blurred or tunnel vision 4
Earaches, ear infections	Earaches, ear infections 0	Earaches, ear infections 1	Earaches, ear infections 2	Earaches, ear infections 3	Earaches, ear infections 4
Ringing in ears, hearing loss	Ringing in ears, hearing loss 0	Ringing in ears, hearing loss 1	Ringing in ears, hearing loss 2	Ringing in ears, hearing loss 3	Ringing in ears, hearing loss 4
Stuffy nose	Stuffy nose 0	Stuffy nose 1	Stuffy nose 2	Stuffy nose 3	Stuffy nose 4
Sinus problems	Sinus problems 0	Sinus problems 1	Sinus problems 2	Sinus problems 3	Sinus problems 4
Hay fever	Hay fever 0	Hay fever 1	Hay fever 2	Hay fever 3	Hay fever 4
Excessive mucus formation	Excessive mucus formation 0	Excessive mucus formation 1	Excessive mucus formation 2	Excessive mucus formation 3	Excessive mucus formation 4
Chronic coughing	Chronic coughing 0	Chronic coughing 1	Chronic coughing 2	Chronic coughing 3	Chronic coughing 4
Gagging, frequent need to clear throat	Gagging, frequent need to clear throat 0	Gagging, frequent need to clear throat 1	Gagging, frequent need to clear throat 2	Gagging, frequent need to clear throat 3	Gagging, frequent need to clear throat 4
Sore throat, hoarseness, loss of voice	Sore throat, hoarseness, loss of voice 0	Sore throat, hoarseness, loss of voice 1	Sore throat, hoarseness, loss of voice 2	Sore throat, hoarseness, loss of voice 3	Sore throat, hoarseness, loss of voice 4
Swollen or discoloured tongue, gums or lips	Swollen or discoloured tongue, gums or lips 0	Swollen or discoloured tongue, gums or lips 1	Swollen or discoloured tongue, gums or lips 2	Swollen or discoloured tongue, gums or lips 3	Swollen or discoloured tongue, gums or lips 4
Acne	Acne 0	Acne 1	Acne 2	Acne 3	Acne 4
Hives, rashes, dry skin	Hives, rashes, dry skin 0	Hives, rashes, dry skin 1	Hives, rashes, dry skin 2	Hives, rashes, dry skin 3	Hives, rashes, dry skin 4
Hair loss	Hair loss 0	Hair loss 1	Hair loss 2	Hair loss 3	Hair loss 4
Flushing, hot flashes	Flushing, hot flashes 0	Flushing, hot flashes 1	Flushing, hot flashes 2	Flushing, hot flashes 3	Flushing, hot flashes 4
Excessive sweating	Excessive sweating 0	Excessive sweating 1	Excessive sweating 2	Excessive sweating 3	Excessive sweating 4
Chest pain	Chest pain 0	Chest pain 1	Chest pain 2	Chest pain 3	Chest pain 4
Irregular or skipped heartbeat	Irregular or skipped heartbeat 0	Irregular or skipped heartbeat 1	Irregular or skipped heartbeat 2	Irregular or skipped heartbeat 3	Irregular or skipped heartbeat 4
Chest congestion	Chest congestion 0	Chest congestion 1	Chest congestion 2	Chest congestion 3	Chest congestion 4
Asthma, bronchitis	Asthma, bronchitis 0	Asthma, bronchitis 1	Asthma, bronchitis 2	Asthma, bronchitis 3	Asthma, bronchitis 4
Difficulty breathing	Difficulty breathing 0	Difficulty breathing 1	Difficulty breathing 2	Difficulty breathing 3	Difficulty breathing 4
Nausea, vomiting	Nausea, vomiting 0	Nausea, vomiting 1	Nausea, vomiting 2	Nausea, vomiting 3	Nausea, vomiting 4
Diarrhea	Diarrhea 0	Diarrhea 1	Diarrhea 2	Diarrhea 3	Diarrhea 4
Constipation	Constipation 0	Constipation 1	Constipation 2	Constipation 3	Constipation 4
Bloated feeling	Bloated feeling 0	Bloated feeling 1	Bloated feeling 2	Bloated feeling 3	Bloated feeling 4
Belching, passing gas	Belching, passing gas 0	Belching, passing gas 1	Belching, passing gas 2	Belching, passing gas 3	Belching, passing gas 4
Heartburn	Heartburn 0	Heartburn 1	Heartburn 2	Heartburn 3	Heartburn 4
Intestinal/stomach pain	Intestinal/stomach pain 0	Intestinal/stomach pain 1	Intestinal/stomach pain 2	Intestinal/stomach pain 3	Intestinal/stomach pain 4
Pain or aches in joints	Pain or aches in joints 0	Pain or aches in joints 1	Pain or aches in joints 2	Pain or aches in joints 3	Pain or aches in joints 4
Arthritis	Arthritis 0	Arthritis 1	Arthritis 2	Arthritis 3	Arthritis 4
Stiffness or limitation of movement	Stiffness or limitation of movement 0	Stiffness or limitation of movement 1	Stiffness or limitation of movement 2	Stiffness or limitation of movement 3	Stiffness or limitation of movement 4
Feeling of weakness or tiredness	Feeling of weakness or tiredness 0	Feeling of weakness or tiredness 1	Feeling of weakness or tiredness 2	Feeling of weakness or tiredness 3	Feeling of weakness or tiredness 4
Pain or aches in muscles	Pain or aches in muscles 0	Pain or aches in muscles 1	Pain or aches in muscles 2	Pain or aches in muscles 3	Pain or aches in muscles 4
Binge eating/drinking	Binge eating/drinking 0	Binge eating/drinking 1	Binge eating/drinking 2	Binge eating/drinking 3	Binge eating/drinking 4
Craving certain foods	Craving certain foods 0	Craving certain foods 1	Craving certain foods 2	Craving certain foods 3	Craving certain foods 4
Excessive weight	Excessive weight 0	Excessive weight 1	Excessive weight 2	Excessive weight 3	Excessive weight 4
Water retention	Water retention 0	Water retention 1	Water retention 2	Water retention 3	Water retention 4
Underweight	Underweight 0	Underweight 1	Underweight 2	Underweight 3	Underweight 4
Compulsive eating	Compulsive eating 0	Compulsive eating 1	Compulsive eating 2	Compulsive eating 3	Compulsive eating 4
Fatigue, sluggishness	Fatigue, sluggishness 0	Fatigue, sluggishness 1	Fatigue, sluggishness 2	Fatigue, sluggishness 3	Fatigue, sluggishness 4
Apathy, lethargy	Apathy, lethargy 0	Apathy, lethargy 1	Apathy, lethargy 2	Apathy, lethargy 3	Apathy, lethargy 4
Hyperactivity	Hyperactivity 0	Hyperactivity 1	Hyperactivity 2	Hyperactivity 3	Hyperactivity 4
Restlessness	Restlessness 0	Restlessness 1	Restlessness 2	Restlessness 3	Restlessness 4
Poor memory	Poor memory 0	Poor memory 1	Poor memory 2	Poor memory 3	Poor memory 4
Confusion, poor comprehension	Confusion, poor comprehension 0	Confusion, poor comprehension 1	Confusion, poor comprehension 2	Confusion, poor comprehension 3	Confusion, poor comprehension 4
Difficulty in making decisions	Difficulty in making decisions 0	Difficulty in making decisions 1	Difficulty in making decisions 2	Difficulty in making decisions 3	Difficulty in making decisions 4
Stuttering or stammering	Stuttering or stammering 0	Stuttering or stammering 1	Stuttering or stammering 2	Stuttering or stammering 3	Stuttering or stammering 4
Slurred speech	Slurred speech 0	Slurred speech 1	Slurred speech 2	Slurred speech 3	Slurred speech 4
Learning disabilities	Learning disabilities 0	Learning disabilities 1	Learning disabilities 2	Learning disabilities 3	Learning disabilities 4
Poor concentration	Poor concentration 0	Poor concentration 1	Poor concentration 2	Poor concentration 3	Poor concentration 4
Poor physical coordination	Poor physical coordination 0	Poor physical coordination 1	Poor physical coordination 2	Poor physical coordination 3	Poor physical coordination 4
Mood swings	Mood swings 0	Mood swings 1	Mood swings 2	Mood swings 3	Mood swings 4
Anxiety, irritability, aggressiveness	Anxiety, irritability, aggressiveness 0	Anxiety, irritability, aggressiveness 1	Anxiety, irritability, aggressiveness 2	Anxiety, irritability, aggressiveness 3	Anxiety, irritability, aggressiveness 4
Depression	Depression 0	Depression 1	Depression 2	Depression 3	Depression 4
Frequent illness	Frequent illness 0	Frequent illness 1	Frequent illness 2	Frequent illness 3	Frequent illness 4
Frequent or urgent urination	Frequent or urgent urination 0	Frequent or urgent urination 1	Frequent or urgent urination 2	Frequent or urgent urination 3	Frequent or urgent urination 4
Genital itch or discharge	Genital itch or discharge 0	Genital itch or discharge 1	Genital itch or discharge 2	Genital itch or discharge 3	Genital itch or discharge 4

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* 6. Section B: Xenobiotic Tolerability Test:

Are you presently using prescription drugs?

Yes

If Yes, how many are you currently taking?

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* 7. Are you presently taking one or more of the following over-the-counter drugs?

	Yes	No
Cimetidine	Cimetidine Yes	Cimetidine No
Acetaminophen	Acetaminophen Yes	Acetaminophen No
Estradiol	Estradiol Yes	Estradiol No

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* 8. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them?

Experience side effects, drug(s) is (are) efficacious at lowered dose(s)

Experience side effects, drug(s) is (are) efficacious at usual dose(s)

Experience no side effects, drug(s) is (are) efficacious

Experience no side effects, drug(s) is (are) usually efficacious

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* 9. Do you currently use or within the last 6 months had you regularly used tobacco products?

Yes

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* 10. Do you have strong negative reactions to caffeine of caffeine containing products?

Yes

Don't know

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* 11. Do you commonly experience "brain fog", fatigue, or drowsiness?

Yes

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* 12. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odours?

Yes

Don't know

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* 13. Do you feel ill after you consume even small amounts of alcohol?

Yes

Don't know

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* 14. Do you have a personal history of

Environmental and/or chemical sensitivities

Chronic fatigue syndrome

Multiple chemical sensitivity

Fibromyalgia

Parkinson's type symptoms

Alcohol or chemical dependence

Asthma

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* 15. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?

Yes

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* 16. Do you have an adverse or allergic reaction when you consume sulphite containing foods such as wine, dried fruit, salad bar, vegetables, etc?

Yes

Don't know

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* 17. Section C: Alkalising Assessment:

Please answer Yes / No to the following questions:

	Yes	No
Do you have a history or currently have kidney dysfunction?	Do you have a history or currently have kidney dysfunction? Yes	Do you have a history or currently have kidney dysfunction? No
Have you ever been diagnosed with a condition known as hyperkalemia?	Have you ever been diagnosed with a condition known as hyperkalemia? Yes	Have you ever been diagnosed with a condition known as hyperkalemia? No
Are you currently on diuretics or blood pressure medication?	Are you currently on diuretics or blood pressure medication? Yes	Are you currently on diuretics or blood pressure medication? No

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* 1. Please take a few moments to complete our Detoxification Survey. When your questionnaire is complete, a Health Renewal doctor will evaluate your answers. Please tick the box below if you agree that a Health Renewal doctor can call you to discuss your score?

Question Title

* 2. What is your Name and Surname?

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* 3. Which Renewal Institute branch is your home branch?

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* 4. Please select your Gender?

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* 6. Section B: Xenobiotic Tolerability Test:Are you presently using prescription drugs?

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* 7. Are you presently taking one or more of the following over-the-counter drugs?

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* 8. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them?

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* 9. Do you currently use or within the last 6 months had you regularly used tobacco products?

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* 10. Do you have strong negative reactions to caffeine of caffeine containing products?

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* 11. Do you commonly experience "brain fog", fatigue, or drowsiness?

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* 12. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odours?

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* 13. Do you feel ill after you consume even small amounts of alcohol?

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* 14. Do you have a personal history of

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* 15. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?

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* 16. Do you have an adverse or allergic reaction when you consume sulphite containing foods such as wine, dried fruit, salad bar, vegetables, etc?

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* 17. Section C: Alkalising Assessment:Please answer Yes / No to the following questions:

* 6. Section B: Xenobiotic Tolerability Test:

Are you presently using prescription drugs?

* 17. Section C: Alkalising Assessment:

Please answer Yes / No to the following questions: