Toxicity Assessment Form Directions Please complete this form before beginning your detoxification. We want to be able to track your symptoms and measure how they are improving throughout your detox treatments. Name* First Last Email* Date* Date Format: DD slash MM slash YYYY Emotional and Mental HealthDo you currently feel stressed?*YesNo Do you struggle to get parasympathetic? (ie. out of stress mode and into rest/chill out mode)?*YesNo Do you take any anti-anxiety medication?*Yesno Do you take any anti-depressant medication?*YesNo Has life presently lost its shine?*YesNo Do you suffer from anxiety?*YesNo Do you feel tired?*YesNo Does life feel harder than it used to be?*YesNo Do you have a foggy brain? Can’t think as clearly as you used to?*YesNo Do you have difficulty focusing during the day?*YesNo Do you have problems sleeping?*YesNo Do you struggle to fall asleep?*YesNo Do you wake up during the night?*YesNo Do you experience hot sweats at night?*YesNo Do you experience hot sweats during the day?*YesNo PhysicalDo you get acne?*YesNo Do you have skin flares or eczema?*YesNo Do you ever get cold sore outbreaks?*YesNo Have you had glandular fever?*YesNo Do you regularly (ie daily) pass sausage stools?*YesNo Do you experience constipation?*YesNo Do you experience loose bowels?*YesNo Are you wanting to loose weight*YesNo Do you have sore joints or muscles?*YesNo Do you get liver spots?*YesNo Does your body feel inflamed?*YesNo Do you have body odour?*YesNo Do you have gout?*YesNo Do you have poor circulation?*YesNo For females, does your menstrual cycle cause you pain, or have an impact on your day to day life?YesNo Are you aware of any heavy metal toxicity in your body?*YesNo Do you have any amalgam fillings?*YesNo Are you on any medication?*YesNo If so what are you taking? Additional conditions/symptoms not listed above