Detox Questionnaire

Find out if PERQUE’s Detox Kit is right for you.

Please give each question a value
ranging from 0-5 with 0 representing not being
true for you and 5 describing you very well.

Question Title

* 1. Do you tire easily?

0

1

2

3

4

5

Question Title

* 2. Have you become more irritable recently?

0

1

2

3

4

5

Question Title

* 3. Do you sleep poorly (awaken before fully rested)?

0

1

2

3

4

5

Question Title

* 4. Do you sweat more than what is usual for you?

0

1

2

3

4

5

Question Title

* 5. Do you experience bloating?

0

1

2

3

4

5

Question Title

* 6. Do you have skin conditions like brown spots, acne, or eczema?

0

1

2

3

4

5

Question Title

* 7. Are you allergic or sensitive to certain foods, car fumes, or perfumes?

0

1

2

3

4

5

Question Title

* 8. Do you have trouble losing weight?

0

1

2

3

4

5

Question Title

* 9. Do you get headaches frequently?

0

1

2

3

4

5

Question Title

* 10. Are you experiencing any difficulty concentrating?

0

1

2

3

4

5