Toxicity Symptom Questionnaire Question Title * Record your symptoms over the past 3 months DIGESTIVE Nausea or Vomiting Diarrhea Constipation Bloating Belching or gas Heartburn EYES Watery or itchy Swollen, red or irritated eyelids Dark circles under eyes EARS Itchy ears Earaches or fluid in ears Ringing in ears HEAD Headaches Faintness Dizziness EMOTIONS Mood swings Anxiety, fear or nervousness Depression or sadness LUNGS Chest congestion Shortness of Breath Asthma or bronchitis ENERGY/ACTIVITY Fatigue or Sluggishness Restlessness Insomnia MIND Poor Memory Brain Fog Difficulty making decisions Poor concentration MOUTH/THROAT Chronic coughing Swollen or discolored tongue, gums, or lips Gagging or need to clear throat NOSE Stuffy nose Sinus problems Sneezing attacks Excessive mucous SKIN Acne Hives, rashes or dry skin Hair loss HEART Skipping or rapid heartbeats Chest pains High cholesterol/triglycerides/blood sugar JOINTS/MUSCLES Pain or aches in joints or muscles Stiffness or limited movement Feeling weak or tired in limbs WEIGHT Binge eating or craving certain foods Swelling or water retention Gained 5lbs in past 3 months OTHER Frequent Illness Frequent or urgent urination Leaky bladder or UTI’s TOXIN EXPOSURE Use scented cleaners/candles/nail polish/cosmetics Drink public water Eat packaged food Use pesticides/herbicides in around home Live near farmland Take Medication OTC or Prescribed Question Title * Click the Done button to see your results! (The number of points you scored will reveal your toxicity level) 0-3 Great! Detox for prevention 4-7 OK! Quick Cleanse would take health to new level 8-12 Poor! A detox will benefit your health 12+ Bad! In serious need of a change, detox 2x a year For more information about our Whole Body Detoxes check out our website! Done