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QUESTIONNAIRE: DETOXIFICATION REQUIREMENTS

Section 1

VALUE EQUIVALENT
0 = Rarely/Never; 1= Occasionally/Once every other week; 2 = Sometimes/Once or twice a week; 3 = Often/A few times a week; 4 = Always/Daily
1.YOUR DETAILS
2.Do you consume less than five cups of vegetables and/or salad daily?
3.How often do you eat non-organic foods?
4.Do you drink alcohol?
5.Do you use ‘social’ or ‘recreational’ drugs?
6.Are you, or have you been, exposed to heavy traffic, exhaust fumes and pollution?
7.Are you regularly exposed to nail polish, hair dyes and similar products?
8.Do you suffer from headaches or migraines?
9.Do you suffer from allergies or asthma?
10.Have you lost/are you trying to lose a significant amount of weight?
11.Do you pass stools that are slightly loose or not well-formed?
12.Is there mucus or blood in your bowel motion?
13.Do you take pharmaceutical anti-inflammatory or pain relief medicines?
14.Are you or your partner planning on becoming pregnant in the next six months?
15.Do you eat processed meat, or fatty meat such as ham, salami, devon or sausages?
16.Do you drink more than four alcoholic drinks in one sitting?
17.Does your diet contain soft drink and/or junk food (e.g. chips, chocolate, biscuits, lollies, cakes, cookies)?
18.Do you consume food or drink from plastic, plastic-lined containers, tin or aluminum? (e.g. bottled water, disposable coffee cups, canned food, aluminum cans, takeaway food containers)?
19.Are you, or have you been, exposed to insecticides, pesticides or herbicides in the last 12 months (e.g. had your home sprayed for pests, or used weed killing sprays, termite or flea treatments)?
20.Do you use synthetic cleaning products at home (e.g. disinfectants, detergents, bleach, polishes and similar products)?
21.Do you suffer from fatigue?
22.Do you currently suffer with any skin conditions (e.g. eczema, acne and/or rosacea)?
23.Do you experience PMS, irregular periods or heavy periods?
24.Do you have trouble losing weight or regain lost weight quickly?
25.Do you feel a sensation of incomplete emptying of the bowel?
26.Have you been on a course of antibiotics in the last 12 months?
27.Are you taking or have you previously been on proton pump inhibitors?
28.Have you done a Practitioner guided detoxification in the past six months?
29.Do you experience abdominal bloating?
30.Do you experience excessive burping?
31.Do you suffer from excessive flatulence, wind or foul smelling wind?
32.Do you suffer from heartburn, indigestion or reflux/acid regurgitation?
33.Do you experience constipation (less than one bowel motion a day)?
34.Do you suffer from oral or vaginal thrush (candida)?
35.Do you suffer from abdominal pain or discomfort?
36.Do you experience nausea or loss of appetite?
37.Do you get diarrhoea?
38.Have you been diagnosed with IBS or IBD?
39.Have you worked, or do you work, with metals (e.g. as a plumber, gas fitter, foundry worker, welder; or in electroplating, stained glass (leadlight) fabrication etc.)?
40.Do you have a new (less than one year old) car, furniture or carpets; or have you ever renovated an old house?
41.Do health complaints reappear or worsen during weight loss?
42.Do you get numbness, tingling or weakness in parts of your body?
43.Do you have, or have you ever had, mercury amalgam dental fillings (silver/grey, not white)?
44.Do you have difficulties thinking, adding up numbers, learning or reasoning, or finding the right word to express yourself?
45.Do you have trouble remembering things?
46.Do you have occupational or regular exposure to pesticides, herbicides, paints, solvents, glues, petroleum products, industrial cleaning products; or do you work with other chemicals?
47.Do you smoke? Or have you previously smoked regularly in the last four years?
48.Are any of your symptoms worsened by exposure to substances such as alcohol, cigarette smoke, vehicle exhaust, perfumes and cleaning products (e.g. certain aisles in supermarkets or department stores) or similar?