Detox Questionnaire

Detoxification Requirements

Answer all the questions below to determine if you need to detox, and whether you need a specialised detox
Name*

First NameLast Name
E-mail*
Section 1a: General - Diet, Lifestyle and Symptoms
1. How much of the food you eat each week is ‘spray-free’ or organically grown or raised?*

All or mostAround halfSomeNone
2. How often do you eat fruit? One serve = one handful*

2+ serves daily1 serve dailyWeeklyMonthlyNever or rarely
3. How often do you eat vegetables (excluding potatoes)? One serve = one handful*

5+ serves daily2-4 serves dailyDailyWeeklyMonthlyNever or rarely
4. How often do you eat animal products? (e.g. dairy foods, eggs, poultry, red meat or fish)*

Never or rarelyMonthlyWeeklyOnce a dayTwice a dayMost meals
5. Do you drink filtered water?*

Always or mostlySometimesNever or rarely
6. How often would you have tinned food?*

Never or rarelyMonthlyWeeklyDaily
7. How often do you eat ‘fast’ or ‘junk’ food? (e.g. takeaway, deep fried, snack food)*

Never or rarelyMonthlyWeeklyDaily
8. How often do you drink more than 4 standard alcoholic drinks in one session?*

Never or rarelyMonthlyWeekly: 1-2timesWeekly: 3-6timesDaily
9. Do you use ‘social’ or ‘recreational’ drugs? (e.g. marijuana, ecstasy, etc.)*

NeverRarelyMonthlyWeeklyDaily
10. How many ‘personal care’ products do you use? (e.g. soap, cleanser, shampoo, conditioner, antiperspirants, moisturiser, special creams, cosmetics: foundation, eyeliner, eyeshadow, lipstick, perfumes)*

0-5 daily6-10 daily11-20 daily21+ daily
11. Do you feel unusually tired?*

NeverSometimesOftenAlways
12. Do you have any skin issues? (e.g. acne, eczema, rashes)*

NoneSlightModerateSevere
13. Do you suffer from headaches or migraines?*

Never or rarelyMonthlyWeeklyDaily
14. Do you suffer from allergies or asthma?*

NeverSlightModerateSevere
Section 1a - General Section Total
Section 1b: History

Do you have, or is there a personal history of:*

	No Personal or Family History	Family History	Personal History (past)	Personal History (current)
15. Cancer
16. Autoimmune Disorders (inc. Type 1 diabetes)
17. Hormonal Disorders (eg fibroids, endometriois, reproductive problems, thyroid)
18. Diabetes (Type 2)
19. Fibromyalgia &/or chronic fatigue syndrome
20. Heart Disease

Section 2a - Medical History Total
Section 2: Gut

Please select an answer to each question*

	Never	Rarely	Monthly	Weekly	Daily
21. Do you get diarrhoea (loose &/or frequent stool)
22. Is there mucus or blood in your bowel motion?
23. Do you suffer from heartburn, burping, nausea or reflux/acid regurgitation requiring antacid medication?
24. Do you experience abdominal bloating, fullness or pain?
25. Do you feel a sensation of incomplete emptying of the bowel?
26. Do you experience constipation (less than one bowel motion a day)?
27. Do you suffer from thrush (candida)?
28. Do you take pharmaceutical anti-inflammatory or pain relief medicines?

Gut table 1 total

Have you been diagnosed with a gut disorder such as:*

	No	Yes
29. Small intestinal bacterial overgrowth (SIBO)
30. Inflammatory bowel disease (IBD - ulcerative colitis, Crohn's disease), or irritable bowel syndrome (IBS)
31. Peptic ulcer (stomach/gastric, duodenal)
32. Do you have any food allergies or sensitivities (e.g. gluten sensitivity, coeliac disease, dairy intolerance)

Gut table 2 total
33. Have you had a course of antibiotics in the last 5 years*

No1-3 coursesmore than 3 courses
34. Have you had a course of chemotherapeutic agents in the past 5 years?*

NoYes
35. Have you had a course of radiotherapy in the past 5 years?*

NoYes
Part 3 - Gut Total
Section 3: Environmental Toxins/Liver

Select an answer for each question:*

	No	Yes
36. Do you have any liver/gallbladder disease? (e.g. gall stones, hepatitis, fatty liver or jaundice - are the whites of your eyes yellowed?
37. Have you lost/are trying to lose a significant amount of weight?
38. Do you have trouble losing weight?

39. Are you or have you been exposed to heavy trafiic, exhaust fumes and pollution? (e.g. living near a main road, exercising along main roads, commuting, working on roads or in car parks?)*

RarelyMonthlyWeeklyDaily - a few hoursDaily - most of the day
40. Are you or have you been exposed to insecticides, pesticides, or herbicides? (e.g. fly sprays, garden sprays, termite or flea treatments, working on a golf course, orchard or farm)*

RarelyOccasionalWeeklyDaily (occupational)
41. Are you or have you been exposed to paints, solvents, glues, nail polish, hair dyes and similar products?*

RarelyMonthlyWeeklyDaily (occupational)
42. Do you use cleaning products? (e.g. disinfectants, detergents, degreasers, polishes and similar products)*

RarelyMonthlyWeeklyDaily (occupational)
43. Do you consume food or drink from plastic or plastic lined containers? (e.g. bottled water, disposable coffee cups, canned food takeaway food containers)*

NoMonthlyWeeklyDaily
44. Do you experience bouts of anger or irritability?*

RarelyMonthlyWeeklyDaily
45. Do you have a new (less than 3 years old) car, furniture, or carpets?*

NoYes
46. 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 areas in department stores) or similar?*

NoSlightlyModeratelySeverly
Part 4: Environmental Toxins/Liver
Section 4: Metals

Have you...*

	No	Yes
47. ever been diagnosed with heavy metal toxicity? (e.g. lead, mercury, cadmium, arsenic, or similar)
48. lived, or do you live, near a mine, industrial area, paint manufacturing, smelter, forge or foundry?
49. been exposed to arsenic treatments such as termite dusting, working with or burning treated timber?
50. ever renovated an old house? (e.g. exposure to old paint, plumbing)

Do you...*

	Never or rarely	Monthly	Weekly	Daily
51. have difficulties thinking, adding up numbers, learning or reasoning, or finding the right word to express yourself?
52. have trouble remembering things?
53. get numbness, tingling or weakness in parts of the body?

54. 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)*

RarelyOccasionalRegularly (hobby)Daily (occupational)
55. Do you eat large deep-sea predator fish such as tuna, swordfish and shark (flake)?*

NoRarely (less than once a month)Once or twice a monthWeeklySeveral times a week
56. Do you smoke tobacco? (e.g. cigarettes, cigars, pipes)*

NoPast smokerSocially (weekends)A few most daysA packet + daily
57. Do you have, or have you ever had, mercury amalgam dental fillings (silver/grey, not white)*

NoPreviously removed1-3 fillingsMore than 3 fillings
Part 5: Metals
Detox total
Gut Detox Total
Liver Detox Total
Metals Detox Total
General Detox Total
Medical History Total
Should be Empty:

Detoxification Requirements

Section 1a: General - Diet, Lifestyle and Symptoms

Section 1b: History

Section 2: Gut

Section 3: Environmental Toxins/Liver

Section 4: Metals