The Detoxification Questionnaire

The Detoxification Questionnaire is a self-administered test that includes questions about all the major toxicity symptoms. Patients evaluate their symptoms on a scale of 0 to 4. By using this form online it will automatically calculate the score for your use.


EmotionsScore
Irritability 0 1 2 3 4
Nervousness 0 1 2 3 4
Mood swings 0 1 2 3 4
Frequent crying 0 1 2 3 4
Aggressive behavior, ie... road rage 0 1 2 3 4
Anxiety 0 1 2 3 4
Fear 0 1 2 3 4
Confusion 0 1 2 3 4
* Depression 0 1 2 3 4
* Suicidal thoughts 0 1 2 3 4
Total Emotions:

SkinScore
Increased sweating, ear wax, oily skin 0 1 2 3 4
Skin rashes 0 1 2 3 4
Brown spots on hands and face 0 1 2 3 4
Boils 0 1 2 3 4
Skin tags (small hanging warts) 0 1 2 3 4
Acne 0 1 2 3 4
Eczema 0 1 2 3 4
Fever blisters 0 1 2 3 4
Warts 0 1 2 3 4
Total Skin:

Ear, Nose and ThroatScore
Increased salivation 0 1 2 3 4
Mouth ulcers 0 1 2 3 4
Common cold 0 1 2 3 4
Sinusitis 0 1 2 3 4
Sore throats 0 1 2 3 4
* Ear infections 0 1 2 3 4
Hay fever 0 1 2 3 4
Loss of smell 0 1 2 3 4
Cough 0 1 2 3 4
Total Ear, Nose and Throat:

Mind and BrainScore
Hyperactivity 0 1 2 3 4
Stammering when speaking or problem finding words 0 1 2 3 4
Difficulty in concentration 0 1 2 3 4
Sleep disturbance 0 1 2 3 4
Difficulty in making decisions 0 1 2 3 4
Headache 0 1 2 3 4
Poor memory 0 1 2 3 4
Poor coordination 0 1 2 3 4
* Compulsive behavior 0 1 2 3 4
* Sleep disturbance 0 1 2 3 4
Memory loss 0 1 2 3 4
Total Mind and Brain:

Digestive SystemScore
Loose stools 0 1 2 3 4
Diarrhea 0 1 2 3 4
Heartburn 0 1 2 3 4
Constipation 0 1 2 3 4
Bloating 0 1 2 3 4
Abdominal pain 0 1 2 3 4
Intolerance to certain foods 0 1 2 3 4
Nausea or vomiting 0 1 2 3 4
* Severe diarrhea with blood or mucous 0 1 2 3 4
Total Digestive System:

KidneyScore
Increase in urination frequency and amount 0 1 2 3 4
Needing to get up in the night to pass urine 0 1 2 3 4
* Urinary tract infections and cystitis 0 1 2 3 4
* Kidney stones 0 1 2 3 4
* Blood in the urine 0 1 2 3 4
Total Kidney:

Joints and MusclesScore
Fleeting muscle aches or joint aches 0 1 2 3 4
Tendinitis (e.g., tennis elbow, golfer's elbow, achilles
tendinitis) 0 1 2 3 4
Gout 0 1 2 3 4
Arthritis 0 1 2 3 4
Fibromyalgia 0 1 2 3 4
Total Joints and Muscles:

MetabolismScore
Feeling of coldness 0 1 2 3 4
Hypoglycemia 0 1 2 3 4
Craving certain foods 0 1 2 3 4
Water retention 0 1 2 3 4
Obesity 0 1 2 3 4
Cellulite 0 1 2 3 4
Total Metabolism:

* These symptoms are indications of conditions that should not be treated with Heel Detoxification and Drainage protocols alone.


Grand Total:

Detoxification Point Scale
Total Points: Less Than 100

Patient with mild to moderate toxicity
Total Points:Greater than 100

Patient with moderate to severe toxicity.

For more information on clinical assessment of the patient please refer to the Detoxification and Drainage, A Theoretical and Practical Approach booklet available on this Web site, reference page number 38.


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Point Count LegendScore
Never or almost never have the symptom0
Occasionally have it1
Occasionally have it, effect is severe2
Frequently have it, effect is not severe3
Frequently have it, effect is severe4