Directions
To complete the toxicity questionnaire, simply fill in the blank with a 0, 1, 2, or 3 depending on your typical symptoms.
0 = Never feel this symptom
1 = Feel this symptom 1-2 times per month
2 = Feel this symptom weekly
3 = Feel this symptom daily
0 = Never feel this symptom
1 = Feel this symptom 1-2 times per month
2 = Feel this symptom weekly
3 = Feel this symptom daily
Head
Headaches/Migraines
Dizziness/Faintness
Neck tension
Cloudy head
Sinus
Nasal congestion (stuffy nose)
Allergies (seasonal or daily)
Mucus
Sneezing
Nose blowing
Eyes
Dark circles under eyes
Bags under eyes
Itchy eyes
Discharge or watery eyes
Blurred vision
Crusted eyes upon waking
Ears
Itchy ears
Discharge or drainage from ears
Ringing in ears, tinnitus
Excessive wax build up
Blocked or muffled hearing
Teeth
Pain in gums or teeth
Bleeding gums
Silver fillings (Score with a 3 if you have any metal fillings)
Metal crowns or Root canals (Score a 3 for crowns or root canals)
Mouth
Canker sores
Cold sores (herpes virus)
Cracking on lips
Discolored lips
White film on lips upon waking or after eating
Tongue
Red dots on tongue
Sides of tongue have dents (“scalloping”)
White, yellow, or brown coating on tongue
Cracks or lines on tongue
Glands
Swollen lymph nodes (neck, armpits, or groin)
Difficulty swallowing
Loss of voice
Swollen ankles or wrists/hands/fingers
Breathing
Chest tension
Inability to get enough air in
Chest congestion
Chronic cough
Clear throat a lot
Voice hoarseness
Weight
Difficulty losing weight
Gain weight easily
Feel swollen or puffy
Retain water
Binge or compulsive eating
Joints/Muscles
Pain in joints
Muscle stiffness
Limited range of motion
Muscle weakness/Loss of strength
Arthritis
Skin
Acne
Hair loss
Flushing/Hot flashes
Dry, flaky skin
Excessive sweating
Hives or itchiness
Psoriasis, eczema, ringworm or skin rashes
Sleep
Inability to fall asleep
Can’t stay asleep/Wake up frequently
Nightmares
Heart racing at night
Night sweats
Energy
Tired upon waking
Daytime or afternoon fatigue
General lack of energy
Apathy
Lack of ambition or drive
Hyperactivity (can’t sit still - have to always be doing something)
Restlessness (feel uncomfortable with quiet)
Tap feet or shake leg or hands when seated
Decreased libido or sexual function
Digestion
Get tired after meals (especially lunch)
Bloating
Gas
Belching/Burping
Heartburn or indigestion
Diarrhea
Constipation
Stomach or intestinal pain
Nausea or vomiting
Stomach sticks out more as day progresses
Mind
Lack of concentration
Easily distracted or lose train of thought
Difficulty making decisions
Brain fog
Stuttering or difficulty putting together sentences
Uncoordinated or drop things
ADD/ADHD or learning disabilities
Emotions
Anxiety
Overwhelm
Irritability
Anger or rage
Dark thoughts
Sad for no reason
Mood swings
Depressed
High-strung
Seasonal Affective Disorder (SAD)
Immunity
(Score each question below with 10 points if you answered yes)
Frequent colds (more than 2-3 illnesses a year)
Allergies (environmental or non-fatal food sensitivities)
Pneumonia (Score with a 10 if yes within the last 12 months)
Diagnosed disease (Score with a 10 if you have a diagnosed disease)
Unexplained illness (Score with a 10 for an undiagnosed disease)
Total Score
Grand Total Score (add up your total points from above)
Headaches/Migraines
Dizziness/Faintness
Neck tension
Cloudy head
Sinus
Nasal congestion (stuffy nose)
Allergies (seasonal or daily)
Mucus
Sneezing
Nose blowing
Eyes
Dark circles under eyes
Bags under eyes
Itchy eyes
Discharge or watery eyes
Blurred vision
Crusted eyes upon waking
Ears
Itchy ears
Discharge or drainage from ears
Ringing in ears, tinnitus
Excessive wax build up
Blocked or muffled hearing
Teeth
Pain in gums or teeth
Bleeding gums
Silver fillings (Score with a 3 if you have any metal fillings)
Metal crowns or Root canals (Score a 3 for crowns or root canals)
Mouth
Canker sores
Cold sores (herpes virus)
Cracking on lips
Discolored lips
White film on lips upon waking or after eating
Tongue
Red dots on tongue
Sides of tongue have dents (“scalloping”)
White, yellow, or brown coating on tongue
Cracks or lines on tongue
Glands
Swollen lymph nodes (neck, armpits, or groin)
Difficulty swallowing
Loss of voice
Swollen ankles or wrists/hands/fingers
Breathing
Chest tension
Inability to get enough air in
Chest congestion
Chronic cough
Clear throat a lot
Voice hoarseness
Weight
Difficulty losing weight
Gain weight easily
Feel swollen or puffy
Retain water
Binge or compulsive eating
Joints/Muscles
Pain in joints
Muscle stiffness
Limited range of motion
Muscle weakness/Loss of strength
Arthritis
Skin
Acne
Hair loss
Flushing/Hot flashes
Dry, flaky skin
Excessive sweating
Hives or itchiness
Psoriasis, eczema, ringworm or skin rashes
Sleep
Inability to fall asleep
Can’t stay asleep/Wake up frequently
Nightmares
Heart racing at night
Night sweats
Energy
Tired upon waking
Daytime or afternoon fatigue
General lack of energy
Apathy
Lack of ambition or drive
Hyperactivity (can’t sit still - have to always be doing something)
Restlessness (feel uncomfortable with quiet)
Tap feet or shake leg or hands when seated
Decreased libido or sexual function
Digestion
Get tired after meals (especially lunch)
Bloating
Gas
Belching/Burping
Heartburn or indigestion
Diarrhea
Constipation
Stomach or intestinal pain
Nausea or vomiting
Stomach sticks out more as day progresses
Mind
Lack of concentration
Easily distracted or lose train of thought
Difficulty making decisions
Brain fog
Stuttering or difficulty putting together sentences
Uncoordinated or drop things
ADD/ADHD or learning disabilities
Emotions
Anxiety
Overwhelm
Irritability
Anger or rage
Dark thoughts
Sad for no reason
Mood swings
Depressed
High-strung
Seasonal Affective Disorder (SAD)
Immunity
(Score each question below with 10 points if you answered yes)
Frequent colds (more than 2-3 illnesses a year)
Allergies (environmental or non-fatal food sensitivities)
Pneumonia (Score with a 10 if yes within the last 12 months)
Diagnosed disease (Score with a 10 if you have a diagnosed disease)
Unexplained illness (Score with a 10 for an undiagnosed disease)
Total Score
Grand Total Score (add up your total points from above)
Scoring
Take a look at your overall quiz results and see which health sections you seem to be doing the best and what areas need some work. Those are the areas where you have underlying imbalances that must be corrected. After adding up your total point total see what
toxicity stage you’re at below:
toxicity stage you’re at below:
Stage 1: 0-9 points
Congratulations it looks like you’re doing great! You appear to be well and it seems like you have your health under control. Just make sure you are not adding to your total body burden with continued stress, lack of sleep, poor eating, etc.
In terms of detoxification, it is recommendation at this point to only engage in a seasonal 7-day detox to keep up with and remove the continual accumulation of toxins. Do also try to incorporate a healthy daily routine to stay well and balanced.
In terms of detoxification, it is recommendation at this point to only engage in a seasonal 7-day detox to keep up with and remove the continual accumulation of toxins. Do also try to incorporate a healthy daily routine to stay well and balanced.
stage 2: 10-19 points
It looks like you’re doing pretty well, but you’re starting to see the effects of hidden toxicities expressing themselves on the outside as
symptoms. It’s also at this point that you may be moving towards a dis-ease state unless you begin to remove the toxins that you have accumulated. A formal 7, 14, or 21-day detox is advised and then seasonal detoxes after that to maintain optimal health and balance. It is also highly recommended to incorporate daily healthy living routines.
symptoms. It’s also at this point that you may be moving towards a dis-ease state unless you begin to remove the toxins that you have accumulated. A formal 7, 14, or 21-day detox is advised and then seasonal detoxes after that to maintain optimal health and balance. It is also highly recommended to incorporate daily healthy living routines.
Stage 3: 20+ points
Your body is now showing signs of toxic overload and total body burden. Most likely, you are feeling the effects of this toxicity in your
daily life in terms of inflammation, lowered vitality, lowered mood, and less overall “get up and go.” A 21-day detox is recommended followed by a seasonal 7, 14, or 21-day detoxes to decrease toxic accumulation until you reach a score of 10 or less. At that point you can simply drop down to one 7-day detox seasonally/quarterly.
daily life in terms of inflammation, lowered vitality, lowered mood, and less overall “get up and go.” A 21-day detox is recommended followed by a seasonal 7, 14, or 21-day detoxes to decrease toxic accumulation until you reach a score of 10 or less. At that point you can simply drop down to one 7-day detox seasonally/quarterly.
How to Detox
Coming soon!
References
Cabral, S. (2017). The Rain Barrel Effect. South Carolina: CreateSpace Independent Publishing Platform
