i-Detox Client Intake Questionnaires 1/1
The questionnaires below are intended for educational purposes only and are not a replacement for primary care medical screening.
PART I: THE DETOX RISK QUESTIONNAIRE
How toxic might you be? How at risk are you? This part of the questionnaire helps to identify your toxic exposures and generic risks to toxicity based on your lifestyle and your body’s own detoxification efficiency. It takes time for our body to show symptoms of toxic overload. The process of doing this questionnaire may raise your awareness to your toxicity risk before your body shows symptoms. (Part II will address symptoms)
A. Dietary Habits
a. How many serves of refined “white foods” (white bread, sweet breakfast cereals, pasta, noodles, biscuits, pastries, cakes, white rice) do you eat typically per day? (Scale: none = 0, one to two = 1, three to four = 2, five or more = 3)
______
b. How many serves of red meat (not organic) do you consume per week? (including beef, pork, lamb, bacon, sausages) (Scale: none = 0, organic mostly less than five serves = 1, one to three = 1, three to six = 2, six to ten = 3, more than ten = 4)
______
c. How many serves of poultry and diary (not organic) do you consume per week? (including chicken, milk, egg) (Scale: none = 0, organic mostly less than five serves = 1, one to three = 1, three to six = 2, six to ten = 3, more than ten = 4)
______
d. How many total serves of fruits and vegetables do you consume per day? (Scale: five or more = 0, four = 1, two to three = 2, one to two = 3, less than one = 4)
______
e. I drink 7 to 8 glasses of liquid a day, not counting coffee or caffeinated beverages. (Water requirement formula: weight in kg x 30-35ml) (Scale: always = 0, less than that occasionally = 1, less than that half the time = 2, less than that everyday = 3)
______
f. I drink dehydrating beverages like coffee, tea or soda regularly. (Scale: never or almost never = 0, one to two cups a day = 1, two to three cups a day = 2, more than three cups everyday = 3)
______
g. I eat sugar (e.g. candies, chocolate, sugary drinks, sweetened cereals, etc) or use artificial sweetener. (Scale: Never or almost never = 0, Yes = 1, I eat something sugary all through the day = 2, I am addicted to sugar = 3)
______
Subtotal:______
B. Toxic Exposure from Food and Water
a. What percentage of foods you eat is organic? (Scale: 100% = 0, 50% to 70% = 1, less than 50% = 2, less than 10% = 3)
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b. How many serves of shellfish and local fish do you consume per week? (Scale: none = 0, organic and deep water only less than five serves = 1, one = 1, two to four = 2, five to seven = 3, more than seven = 4)
______
c. How often do you eat canned or frozen foods? (Scale: Rarely = 0, 5 to 7 times a month = 1, 3 – 7 times a week = 2)
______
d. How often do you eat foods containing MSG/artificial flavouring? (Scale: Rarely = 0, less than 4 times a week = 1, more than 4 times a week = 2)
______
e. My liquid consumption is from unfiltered water (boiled or unboiled). (Scale: Rarely = 0, 25% of the time = 1, 50% of the time = 2, Most of the time = 4)
______
f. I eat fast food and “junk food”. (Scale: Rarely = 0, two to three times per week = 1, four to five times per week = 2, more than ten times per week = 3)
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g. I eat fried foods, barbecued/burned foods or foods cooked with reused vegetable oil. (Scale: Rarely = 0, two to three times per week = 1, four to five times per week = 2, more than five times per week = 3)
______
Subtotal:______
C. Lifestyle Habits and Environmental Exposure
a. Your sleeping habit. Which describes you most? (Scale: a = 0, b = 1, c = 3, d = 4)
a. I regularly go to bed before 11pm and have adequate sleep.
b. I regularly go to bed between 12 to 2pm and have adequate sleep.
c. I don’t go to bed at a regular time and I generally don’t sleep well.
d. I generally go to bed after 2pm and am sleep deprived.
______
b. How often do you breath fresh air or filtered air by a HEPA filter? (Scale: Rarely = 0, 75% of the time = 1, 50% of the time = 2, 25% of the time = 3, I am indoor most of the time and air is not filtered = 4)
______
c. How often do you take prescription drugs or eat meat that contains antibiotics? (Scale: Rarely = 0, Monthly = 1, Weekly = 2, Daily = 3, Daily & heavily = 4, Daily meat consumption and antibiotics almost every year = 5)
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d. How often do you drink alcohol? (Scale: Rarely = 0, 5 to 7 times a month = 1, 3 – 7 times a week = 2, More than two glasses of wine or equivalent everyday = 3)
______
e. Do you smoke or are you exposed to second hand smoke? (Scale: Never = 0, Weekly or been in the past = 1, Daily = 2, Daily and severely = 3)
______
f. How many mercury fillings do you have in your teeth? (Scale: None = 0, Removed = 1, less than three = 2, more than three = 3, more than five = 4)
______
g. Are you exposed to cell phones, computers, remote control etc everyday? (Scale: No = 0, Yes = 1, Yes and severely = 2)
______
h. Are you exposed to dry cleaned clothes, moth balls, fabric softener, fire retardant, polyester and/or perm press chemical everyday? (Scale: No = 0, Yes = 1, Yes and severely = 2)
i. How often are you exposed to petrochemicals and bleaches? (e.g. household cleaning products, skin care/cosmetics, female sanitary products)
(Scale: I use mostly organic and natural products = 0
About 50% of the products I use are organic = 1
About 30% to 50% of the products I use are organic = 2
None of the products I use are organic or chemical-free = 3)
______
j. I live or work in an environment with treated wood/particle board and conventional paint (Scale: No = 0, Yes = 1)
______
k. My work place or living place has been under renovation in the past year. (Scale: No = 0, Yes = 1, Both = 2)
______
l. I am exposed to foam pillows, mattresses or sofas daily. (Scale: No = 0, Yes = 1)
______
m. I use foam or plastic food containers daily and I use them for heated beverages or food. (Scale: No = 0, Yes but not with heat = 1, Daily and with heat = 2)
______
n. I am exposed to soft plastic disposable water bottle and clear plastic food wrap daily. (Scale: No = 0, Yes = 1)
______
o. I am exposed to mostly incandescent or fluorescent light and rarely get natural light or full spectrum light exposure. (Scale: No = 0, Yes = 1)
______
Subtotal:______
D. How is your elimination system detoxifying?
1. Bowel Movements (Scale: a = 0, b = 1, c = 3, d = 4)
a. I have regular, well formed soft-bowel movements 2 to 3 times a day.
b. I have one bowel movement a day.
c. I have hard, difficult-to-pass movements once a day or once every other day.
d. I am constipated and only go every other or less often.
______
2. Urination (Scale: a = 0, b = 1, c = 3, d = 4)
a. I urinate large volumes of clear light yellow urine regularly throughout the day.
b. I urinate moderate amounts of yellow coloured urine 3-4 times a day.
c. I urinate small amount of dark, strong smelling urine a few times a day.
d. I urinate very dark and strong smelling urine once or twice a day.
______
3. Sweating (Scale: a = 0, b = 1, c = 3, d = 4)
a. I sweat easily and daily through exercise or saunas or hot baths.
b. I sweat profusely 2 – 3 times a week.
c. I sweat lightly a few times a week.
d. I don’t sweat easily and almost never break a sweat.
______
Subtotal:______
E. Do you have a personal or family history of… (Scale 0 = No, 1 = Yes)
a. Breast cancer ______
b. Smoking-induced lung cancer ______
c. Other type of cancer ______
d. Prostate cancer ______
e. Food allergies, sensitivities, or intolerances ______
f. Environmental sensitivities ______
g. Parkinson’s, Alzheimer’s or other motor neuron disease, or multiple sclerosis ______
h. Asthma ______
i. Lupus, rheumatoid arthritis or other autoimmune disease ______
Subtotal:______
Grand total: ______
Interpreting Your Toxicity Score:
Total 25 or lower: You have a low overall risk for problems relating to impaired detoxification.
Total 26 to 50: You detoxification system is at minimal to average risk. Doing the
i-Detox 9-Day program at least once a year would be beneficial to you.
Total 51 to 85: You are at significant risk for diseases and symptoms related to impaired detoxification. You may benefit from the i-Detox 9-Day program two to three times a year.
Total 85 or above: You show a high risk to toxicity and likely need further testing and medical supervision for a prolonged detoxification.
Proceed to Part II to take a more detailed assessment of your possible toxic load based on your symptoms.
Part II: TOXICITY QUESTIONNAIRE
Everyone person’s experience of symptoms is different. This questionnaire gives an indication of your toxicity level based on common symptoms related to toxicity and is not intended as a medical screening.
Take this before and after your detox program. It will help you to monitor the success of your detox efforts.
Rate each of the following symptoms based upon your health profile for the past 30 days.
POINT SCALE:
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
DIGESTIVE _____ Nausea or vomiting
TRACT _____ Diarrhea or watery motions
_____ Constipation (less than one BM daily)
_____ Bloated feeling
_____ Belching, or passing gas
_____ Intestinal/stomach pain
_____ Heartburn, indigestion Total: _____
EARS _____ Itchy ears
_____ Earaches, ear infections
_____ Drainage from ear
_____ Ringing in ears, hearing loss Total: _____
EMOTIONS _____ Mood swings
_____ Anxiety, fear or nervousness
_____ Anger, irritability, or aggressiveness
_____ Depression Total:_____
ENERGY _____ Fatigue/sluggishness
_____ Apathy, lethargy
_____ Hyperactivity
_____ Restlessness Total:_____
EYES _____ Watery or itchy eyes _____ Swollen, reddened or sticky eyelids
_____ Bags or dark circles under eyes
_____ Blurred or tunnel vision
(does not include near- or far-sightedness) Total:_____
HEAD _____ Headaches
_____ Faintness
_____ Dizziness
_____ Insomnia Total:_____
HEART _____ Irregular or skipped heartbeat
_____ Rapid or pounding heartbeat
_____ Chest pain/blocked arteries Total:_____
JOINT/MUSCLES _____ Pain or aches in joints or lower back _____ Arthritis
_____ Stiffness or limitation of movement
_____ Pain or aches in muscles
_____ Feeling of weakness or tiredness Total:____
LUNGS _____ Chest congestion
_____ Asthma, bronchitis
_____ Shortness of breath
_____ Difficulty breathing Total:_____
MIND _____ Poor memory
_____ Foggy headedness, poor comprehension
_____ Poor concentration
_____ Poor physical coordination
_____ Difficulty in making decisions
_____ Stuttering or stammering or slurred speech
_____ Difficulty in learning Total: _____
MOUTH/ _____ Chronic coughing
THROAT _____ Gagging, frequent need to clear throat
_____ Sore throat, hoarseness, loss of voice
_____ Coated tongue, or discoloured gums, lips
_____ Swollen lymph glands
_____ Canker sores, mouth ulcers Total:_____
NOSE _____ Itchy nose
_____ Stuffy nose
_____ Sinus problems
_____ Hay fever/Sneezing attacks
_____ Excessive mucus formation Total:_____
SKIN _____ Acne or red spots on face or body parts
_____ Brown “age/liver spots” on hands or face
_____ Hives, rashes, or eczema
_____ Flushing or hot flashes (not related to menopause)
_____ Body odour
_____ Hair Loss
_____ Greasy skin
_____ Excessive sweating Total:_____
WEIGHT _____ Compulsive eating or drinking
_____ Cravings certain foods
_____ Overweight
_____ Difficulty to lose weight (weight doesn’t shift) _____ Water retention
_____ Underweight, poor appetite Total:_____
OTHER _____ Frequent illness or long recovery time
_____ Recreational drug cravings (including tobaaco and alcohol)
_____ Frequent or urgent urination
_____ Genital itch or discharge
_____ (For female only) Heavy periods Total:_____
GRAND TOTAL : _____
Interpreting Your Toxicity Score:
Total 10 or lower: Congratulations! Your sign of toxicity is low. You may continue your lifestyle and use the i-Detox 9-Day program without the Liver Flush once a year for maintenance.
Total 11 to 20: You are showing mild level of toxicity. You may use the i-Detox 9-Day program once to twice a year.