Cart
0
about
sessions
workshops
online courses
retreats
cooking
yoga therapy
Cart
0
about
sessions
workshops
online courses
retreats
cooking
yoga therapy
Pre-detox
questionnaire
PLEASE ANSWER THE QUESTIONNAIRE
Name
*
First Name
Last Name
Email
*
DO YOU CONSISTENTLY STRUGGLE IN ANY OF THESE AREAS?
Choose yes or no for each area listed below. If your answer would be “maybe” or “sometimes,” choose yes.
1| Energy levels
YES
NO
2| Sugar and carb cravings
YES
NO
3| Sleep quality
YES
NO
4| Bowel movement regularity
YES
NO
5| Mood
YES
NO
6| Productivity
YES
NO
7| Clarity of thought
YES
NO
8| Hunger
YES
NO
9| Motivation
YES
NO
10| Skin acne, rashes, rosacea
YES
NO
11| Gas, bloating, gut issues
YES
NO
12| Sensitivity to smell
YES
NO
13| Joint pain
YES
NO
14| Headaches
YES
NO
15| Difficulty losing weight
YES
NO
What are your top three detox goals?
What are your top three health concerns?
FIND YOUR DETOXIFICATION ABILITY SCORE
Choose the appropriate response. Then add up the points to determine your detoxification ability score.
1| Bowel movements
A) 1 daily, 4 or less days per week
B) 1 daily, at least 5 days per week
C) 1–2 daily
2| Sweating
A) Consistently sweat 1 or less times per week through exercise and/or sauna
B) Consistently sweat 2–3 times per week through exercise and/or sauna
C) Consistently sweat 4 or more times per week through exercise and/or sauna
3| Water intake
A) I don’t drink water and/or I consume caffeinated beverages daily
B) 4–7 glasses of pure spring water daily and 1–2 servings of caffeinated beverages daily
C) 8 or more glasses of pure spring water daily and no more than 1 serving of caffeinated beverages daily
4| Fiber intake (Unsure? If you eat a diet high in processed, refined foods, choose A.)
A) Less than 10 grams per day
B) 10–24 grams per day
C) 25 or more grams per day
5| Digestion (gas, bloating, indigestion)
A) Experience gas/ bloating/indigestion daily
B) Experience gas/ bloating/indigestion 3–5 times per week
C) Experience gas/ bloating/indigestion infrequently – less than once per week
6| Non-starchy vegetables, especially dark green and brightly colored
A) Less than 2 servings daily
B) 2–4 servings daily
C) 5 or more servings daily
7| Exercise
A) Don’t exercise
B) Exercise 1–2 times per week
C) Exercise 3 or more times per week
8| Sulfur-rich foods (e.g., cabbage, broccoli, Brussels sprouts, eggs, onions)
A) 2 or less servings per week
B) 3–4 servings per week
C) 5 or more servings per week
9| Supplements (vitamins, minerals, antioxidants)
A) None
B) Dailyuseofa drugstore or grocery “One a Day” type formula
C) Dailyuseofa professional brand multivitamin
10| Probiotic-rich foods and supplements
A) None
B) Daily use of yogurt, infrequent use of probiotic supplement
C) Daily use of naturally fermented foods and/or probiotic supplement
Give yourself one point for each A answer, two points for each B answer, and 3 points for each C answer. The goal is to get as close to 30 as possible. Work to improve any areas in which you scored only one point.
Detoxification Ability Score:
TOXIC LOAD TEST
1| Alcohol
A) 1 or less drinks per week
B) 2–4 drinks per week
C) 5 or more drinks per week
2| Caffeine
A) None
B) 1–2 caffeinated drinks daily
C) 3 or more caffeinated drinks daily
3| Chemicals
A) Have a nontoxic living and work environment and don’t travel much or use dry cleaning
B) Use organic cleaning products and services and spend time where nontoxic sprays are used (parks, etc.)
C) Use little or no organic cleaning products or services
4| Food
A) Eat organic 90% of the time
B) Eat organic 50% of the time
C) Eat little or no organic food
5| Sugar, processed foods, and artificial sweeteners/colorings
A) I don’t eat anything with added sugar, artificial sweeteners, or colors, and I eat no processed foods
B) I eat some things with sugar, etc.
C) I eat foods with added sugar, etc., 5 or more times per week
6| Cooking
A) I only use nontoxic glass, metal, or “safe” plastic containers and cooking tools
B) I cook with nonstick pans or drink from plastic bottles a few times per week
C) I cook with nonstick pans and/or drink from plastic bottles daily
7| Smoking
A) I don’t smoke, and I’m not around secondhand smoke
B) I smoke infrequently, and I’m sometimes around secondhand smoke
C) I smoke, live with a daily smoker, or work in a smoky environment
8| Vaccines
A) I’ve not been vaccinated at all nor do I get annual flu shots, or it has been more than 10 years for either
B) I have had some flu shots and vaccinations
C) I have been fully vaccinated and get annual flu shots
9| Silver fillings
A) I have no silver fillings
B) I have 3 or less silver fillings or have had them removed by a specially trained dentist
C) I have 4 or more silver fillings
10| Emotional
A) I am easily able to express and handle my feelings and emotions as they arise
B) I sometimes have a hard time managing my emotions
C) I rarely/never share or release my emotions and feelings and usually keep them to myself
Give yourself one point for each A answer, two points for each B answer, and three points for each C answer. A total toxicity score of 26–30 is very high and requires immediate action.
Toxicity Score:
Thank you!
