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 Health
Do you currently feel stressed?*
- Yes
- No
Do you struggle to get parasympathetic? (ie. out of stress mode and into rest/chill out mode)?*
- Yes
- No
Do you take any anti-anxiety medication?*
- Yes
- no
Do you take any anti-depressant medication?*
- Yes
- No
Has life presently lost its shine?*
- Yes
- No
Do you suffer from anxiety?*
- Yes
- No
Do you feel tired?*
- Yes
- No
Does life feel harder than it used to be?*
- Yes
- No
Do you have a foggy brain? Can’t think as clearly as you used to?*
- Yes
- No
Do you have difficulty focusing during the day?*
- Yes
- No
Do you have problems sleeping?*
- Yes
- No
Do you struggle to fall asleep?*
- Yes
- No
Do you wake up during the night?*
- Yes
- No
Do you experience hot sweats at night?*
- Yes
- No
Do you experience hot sweats during the day?*
- Yes
- No
Physical
Do you get acne?*
- Yes
- No
Do you have skin flares or eczema?*
- Yes
- No
Do you ever get cold sore outbreaks?*
- Yes
- No
Have you had glandular fever?*
- Yes
- No
Do you regularly (ie daily) pass sausage stools?*
- Yes
- No
Do you experience constipation?*
- Yes
- No
Do you experience loose bowels?*
- Yes
- No
Are you wanting to loose weight*
- Yes
- No
Do you have sore joints or muscles?*
- Yes
- No
Do you get liver spots?*
- Yes
- No
Does your body feel inflamed?*
- Yes
- No
Do you have body odour?*
- Yes
- No
Do you have gout?*
- Yes
- No
Do you have poor circulation?*
- Yes
- No
For females, does your menstrual cycle cause you pain, or have an impact on your day to day life?
- Yes
- No
Are you aware of any heavy metal toxicity in your body?*
- Yes
- No
Do you have any amalgam fillings?*
- Yes
- No
Are you on any medication?*
- Yes
- No
If so what are you taking?
Additional conditions/symptoms not listed above

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21 Day Detox Reserve Spot

Name
First Last
Email

Directions

Emotional and Mental Health

Physical