Questionnaire

3 Step Detoxification Symptom Questionnaire

Rate each of the following symptoms based upon your typical heath profile.

0 – Never or almost never have the symptom    1 – Occasionally has it, effect is not severe

2- Occasionally have it, effect is severe              3 – Frequently has it, effect is not severe

4 – Frequently has it, effect is severe                        Download pdf file

Digestive

 

Mood swings

 

Anxiety, fear, nervous

 

Anger, irritability

 

Depression

 

Total

Emotions

 

Watery, itchy eyes

 

Swollen, reddened, eyelids

 

Dark circles under eyes

 

Blurred, tunnel vision

 

Total Score

Eyes

 

Chest congestion

 

Asthma, bronchitis

 

Shortness of breath

 

Difficulty breathing

 

Total Score

 

Energy/Activity

 

Itchy ears

 

Earaches, ear infections

 

Drainage from ears

 

Ringing in ears, hearing loss

 

Total Score

Ears

 

Chronic coughing

 

Gagging, need to clear throat

 

Sore throat, hoarse

 

Swollen or discolored tongue, gums or lips

 

Canker sores

 

Total Score

Mouth-Throat

 

Acne

 

Hives, rashes, dry skin

 

Hair loss

 

Flushing, hot flashes

 

Excessive sweating

 

Total Score

Nose

 

Headaches

 

Faintness

 

Dizziness

 

Insomnia

 

Total Score

Head

 

Poor Memory

 

Confusion

 

Poor concentration

 

Poor coordination

 

Difficulty making decisions

 

Stuttering, stammering

 

Slurred speach

 

Learning disabilties

 

Total Score

Mind

 

Skipped heartbeats

 

Rapid heartberats

 

Chest pain

 

Total Score

Joints/Muscles

 

Binge eating/drinking

 

Craving certain foods

 

Excessive weight gain

 

Compulsive eating

 

Water retention

 

Underweight

 

Total Score

 Weight

 

Frequent illness

 

Frequent, urgent urination

 

Genital itch, discharge

 

Total Score

Grand Total___________

Add up the numbers to arrive at a total for each section, then add totals for each section to arrive at the grand total. If any individual section totals is 10 or more, or the grand total is 14 or more, you may benefit from a 3 Step Detoxification Program.

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