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Before You Detox

Before you begin the Core Restore detoxification program, it is important to first evaluate your current health state. This questionnaire will help identify signs of toxic burden. You will take this questionnaire again after your detox program to evaluate your progress. This will help you and your healthcare provider evaluate your success and continued improvement.

Fill Out Your Before You Detox Questionnaire

POINT SCALE: 0 = Never 1 = Occasionally 2 = Frequently

Please add the totals from each section and write the section total in the spaces provided. Then, add all the section totals together and put that total in the space below.

First Name

Last Name

Email

Phone

Digestive

Bowel movements less than once per day

0 = Never

1 = Occasionally

2 = Frequently

Bloated feeling

0 = Never

1 = Occasionally

2 = Frequently

Belching and/or gas

0 = Never

1 = Occasionally

2 = Frequently

Heartburn

0 = Never

1 = Occasionally

2 = Frequently

Total

Skin

Acne

0 = Never

1 = Occasionally

2 = Frequently

Hair loss and/or hair thinning

0 = Never

1 = Occasionally

2 = Frequently

Body odor

0 = Never

1 = Occasionally

2 = Frequently

Excessive sweating

0 = Never

1 = Occasionally

2 = Frequently

Total

Eyes

Watery and/or itchy eyes

0 = Never

1 = Occasionally

2 = Frequently

Swollen and/or reddened eyelids

0 = Never

1 = Occasionally

2 = Frequently

Dark circles under the eyes

0 = Never

1 = Occasionally

2 = Frequently

Blurred vision (excluding near- or far-sightedness)

0 = Never

1 = Occasionally

2 = Frequently

Total

Emotions

Mood swings

0 = Never

1 = Occasionally

2 = Frequently

Feelings of fear and/or nervousness

0 = Never

1 = Occasionally

2 = Frequently

Anger and/or irritability

0 = Never

1 = Occasionally

2 = Frequently

Feelings of sadness

0 = Never

1 = Occasionally

2 = Frequently

Total

Heart

Skipped heartbeats

0 = Never

1 = Occasionally

2 = Frequently

Rapid heartbeats

0 = Never

1 = Occasionally

2 = Frequently

Chest discomfort

0 = Never

1 = Occasionally

2 = Frequently

Total

Mind

Poor memory and/or confusion

0 = Never

1 = Occasionally

2 = Frequently

Difficulty concentrating

0 = Never

1 = Occasionally

2 = Frequently

Poor coordination

0 = Never

1 = Occasionally

2 = Frequently

Difficulty making decisions

0 = Never

1 = Occasionally

2 = Frequently

Total

Energy & Activity

Fatigue and/or sluggishness

0 = Never

1 = Occasionally

2 = Frequently

Hyperactivity

0 = Never

1 = Occasionally

2 = Frequently

Restlessness

0 = Never

1 = Occasionally

2 = Frequently

Occasional sleeplessness

0 = Never

1 = Occasionally

2 = Frequently

Total

Other

Food sensitivities

0 = Never

1 = Occasionally

2 = Frequently

Chemical and/or environmental sensitivities

0 = Never

1 = Occasionally

2 = Frequently

Frequent and/or urgent urination

0 = Never

1 = Occasionally

2 = Frequently

Bloating and/or mood swings before menstruation

0 = Never

1 = Occasionally

2 = Frequently

Total

Ears

Itchy ears

0 = Never

1 = Occasionally

2 = Frequently

Earaches

0 = Never

1 = Occasionally

2 = Frequently

Drainage from ear

0 = Never

1 = Occasionally

2 = Frequently

Ringing in ears and/or hearing loss

0 = Never

1 = Occasionally

2 = Frequently

Total

Head

Headaches

0 = Never

1 = Occasionally

2 = Frequently

Pressure

0 = Never

1 = Occasionally

2 = Frequently

Dizziness

0 = Never

1 = Occasionally

2 = Frequently

Faintness

0 = Never

1 = Occasionally

2 = Frequently

Total

Joints & Muscles

Pain or aches in joints and/or lower back

0 = Never

1 = Occasionally

2 = Frequently

Stiffness and/or limitation in movement

0 = Never

1 = Occasionally

2 = Frequently

Pain or aches in muscles

0 = Never

1 = Occasionally

2 = Frequently

Feelings of weakness and/or tiredness

0 = Never

1 = Occasionally

2 = Frequently

Total

Nose

Stuffy nose

0 = Never

1 = Occasionally

2 = Frequently

Sinus congestion

0 = Never

1 = Occasionally

2 = Frequently

Sneezing

0 = Never

1 = Occasionally

2 = Frequently

Mucus

0 = Never

1 = Occasionally

2 = Frequently

Total

Lungs

Shortness of breath

0 = Never

1 = Occasionally

2 = Frequently

Difficulty breathing

0 = Never

1 = Occasionally

2 = Frequently

Chest congestion

0 = Never

1 = Occasionally

2 = Frequently

Total

Weight

Underweight

0 = Never

1 = Occasionally

2 = Frequently

Overweight

0 = Never

1 = Occasionally

2 = Frequently

Difficulty losing weight

0 = Never

1 = Occasionally

2 = Frequently

Crave certain foods

0 = Never

1 = Occasionally

2 = Frequently

Total

Mouth & Throat

Coughing

0 = Never

1 = Occasionally

2 = Frequently

Gagging and/or frequent need to clear throat

0 = Never

1 = Occasionally

2 = Frequently

Hoarseness and/or loss of voice

0 = Never

1 = Occasionally

2 = Frequently

Dental problems

0 = Never

1 = Occasionally

2 = Frequently

Total

Please add the totals from each section and write the section total in the spaces provided. Then, add all the section totals together and put that total in the space below.

Grand Total

INTERPRETING YOUR TOXICITY SCORE:

10 or lower: You have a low level of toxic burden

11 to 30: You have a moderate level of toxic burden

31 or higher: You have a high level of toxic burden

Low Toxic Burden Recommended Detoxification Program

You are doing pretty well. A 7-day Detoxification Program can still be highly beneficial to reset your eating habits and cravings.

Moderate Toxic Burden Recommended Detoxification Program

Let's get ahead of this! A 7-day Detoxification Program is recommended.

High Toxic Burden Recommended Detoxification Program

Let's tackle this problem head on! A 14-day detoxificaton program is recommended.

Thanks for submitting!

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