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General Health Questionnaire

Use this questionnaire to gauge your progress before and after cleansing.†

Fill this out three days before starting a cleanse and again three days after finishing a cleanse.

Please let us know your results, we love to hear from our customers!

Instructions

  1. Print a copy of this questionnaire.
  2. Circle yes or no to answer the questions.
  3. Fill in your score where indicated.
  4. Save this questionnaire and compare your results from before cleansing with after.

Today's Date: ______________________

Overall Well-Being

Consider your current symptoms and overall sense of well-being.

Do you feel basically healthy? Yes No
Do you consider yourself happy? Yes No

List any negative health symptoms you're experiencing:

 

 

 

 

Do You Have Chronic Inflammation in Your Body?

If you answer "yes" to three or more questions, you may have chronic inflammation.

Do you have elevated cholesterol or triglycerides? Yes No
Do you have numbness or tingling in your arms or legs? Yes No
Do you eat meat, commercially baked sweets, fried foods, or use vegetable oil daily? Yes No
Do you consume fish less than two times per week? Yes No
Do you have high blood pressure, asthma, or colitis? Yes No
Do you smoke? Yes No
Do you have gingivitis, periodontal disease, or not have regular dental cleanings and check-ups at least once every six months? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Nutrition & Lifestyle

Do You Have Poor Nutrition or Digestion?

If you answer "yes" to four or more questions, you may not get enough nutrition or you may experience poor digestion.

Do you regularly include fast food in your diet (three or more times per week)? Yes No
Do you experience belching, bloating, or persistent fullness soon after eating, or do you experience excess gas often? Yes No
Do you experience heartburn or acid reflux two or more times per week? Yes No
Are you allergic to any specific foods? Yes No
Do you feel fatigued or lethargic after eating? Yes No
Do you commonly have bad breath or a bad taste in your mouth? Yes No
Do you use digestive aids such as laxatives, antacids, or acid-blocking drugs? Yes No
Do you often feel "older" than you should for your age? Yes No
Does your skin look sallow, gray, puffy, wrinkled, or aged? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Do You Have Abnormal Blood Sugar Levels?

If you answer "yes" to three or more questions, you may have imbalanced blood sugar or be at risk for diabetes.

Does your waistline extend beyond your hips or are you overweight? Yes No
Do you become tired or light-headed or do you feel the need to eat again just two or three hours after your last meal? Yes No
Do you eat dried beans e.g. pinto, navy, black, etc. less than three times per week? Yes No
Do you exercise less than three times each week? Yes No
Do you eat two or more servings of bread, pasta, candy, colas, or fruit juice a day? Yes No
Do you eat fewer than five servings of fresh, raw vegetables and fruits per day? Yes No
Do you have high blood triglyceride levels or suffer from hypertension? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Do You Have Impaired Cellular or Mitochondrial Function?

If you answer "yes" to three or more questions, you may have impaired cellular function.

Are you frequently tired for no reason (especially around 3 P.M.)? Yes No
Do you have stiff and sore muscles (unrelated to recent exercise)? Yes No
Do you have poor stamina, shortness of breath, or feel exhausted after exercising? Yes No
Do you exercise less than two hours per week? Yes No
Have you ever been diagnosed with iron deficiency or do you have heavy menses? Yes No
Do you look older than your true age? Yes No
Have you ever been exposed to toxic chemicals or heavy metals? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Exposure to Toxins

Is Your Detoxification Capacity Impaired?

If you answer "yes" to four or more questions , your body's detoxification capabilities need a boost.

Do you become physically ill when exposed to strong smells (perfume, auto-exhaust, cigarette smoke, etc.)? Yes No
Do you use chemical cleaners or solvents at home, at work, or in your hobbies? Yes No
Do you live in a house/apartment or work in an office less than 5 years old? Yes No
Do you have any amalgam (mercury) dental fillings? Yes No
Are you prone to side effects from medications or supplements, or have you become more sensitive to the effects of alcohol or caffeine (reduced tolerance)? Yes No
Do you have fewer than 2 bowel movements daily? Yes No
Do you smoke? Yes No
Do you have or have you ever had breast implants? Yes No
Do you have any pets, especially dogs, cats, birds, or other furred or feathered animals? Yes No
Do you wake up often during the night to urinate? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Are Your Home or Work Environment Toxic?

If you answer "yes" to four or more questions, your home or office needs a health makeover.

Do you have carpet in your home? Yes No
Do you vacuum less than 3 times per week? Yes No
Have you changed or cleaned your air filters in the last 30 days? Yes No
Do you routinely drink tap water? Yes No
Are your clothes and bedding washed in unfiltered city water? Yes No
Have you recently repainted your home on the inside? Yes No
Have you noticed any black spots or mold on your air vents or walls? Yes No
Have you had your air vents cleaned in the past year? Yes No
Do you use chemical-based cleaners in your home? Yes No
Do you use chemical fertilizers, insecticides, or pesticides? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Immune System Health

How Strong Is Your Immune System?

If you answer "yes" to four or more questions, your immune system may be stressed.

Do you catch colds or the flu easily? Yes No
Do colds, flu, or other infections tend to linger in your system for more than 5 days? Yes No
Do you have a chronic cough, scratchy throat, sinus congestion, or excess mucus production making it necessary to clear your throat often? Yes No
Do you have seasonal allergies or known allergies to dust, animals, or mold? Yes No
Have you ever been diagnosed with an autoimmune disease? Yes No
Do you have dark circles under your eyes? Yes No
Do you have difficulty seeing at night, or do you have white spots on your fingernails? Yes No
Have you recently had any vaccinations? Yes No
Have you or anyone in your family served in the military in the last 15 to 20 years? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Is Your Liver Impaired?

If you answer "yes" to five or more questions, your liver may be impaired.

Do you feel angry from time to time? Yes No
Are you agitated easily? Yes No
Do you have frequent mood swings? Yes No
Is it hard to stay in a good mood? Yes No
Do you run out of energy during the day? Yes No
Do you have brown spots on your skin or age spots? Yes No
Does your skin break out or is it blemished? Yes No
Are your emotions often on a "roller coaster"? Yes No
Do you later have to apologize for your bad moods to friends, family, co-workers, etc.? Yes No
Is there always "something wrong" in your life? Yes No
Have you ever been physically or sexually abused? Yes No
If you are upset, is it best not to talk to you about what's going on? Yes No
Do you get annoyed by the "fake" cheeriness of others? Yes No
Do these questions irritate you? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Are Your Kidney & Urinary System Functioning Properly?

If you answer "yes" to five or more questions, your kidneys may be overworked.

Do you have pain in your muscles and joints? Yes No
Have you had kidney or bladder infections in the last year? Yes No
Have you experienced ankle pain or swelling in the last year? Yes No
Do you have left shoulder pain? Yes No
Do your fingernails chip or break easily? Yes No
Do you have puffiness, "bags", or dark circles under your eyes? Yes No
Is your hair thinning? Yes No
Do you have frequent scalp irritations? Yes No
Do you have painful, harsh menstrual cycles? Yes No
Do you wake up often during the night to urinate? Yes No
Do you feel exhausted in the morning even after sleeping for 8 or more hours? Yes No
Have you ever been diagnosed with thyroid problems? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Do You Have Parasites or Harmful Organisms?

If you answer "yes" to four or more questions, you may need a thorough harmful organism cleanse.

Do you have any yellowish discoloration on your fingernails or toenails? Yes No
Do you have athlete's foot or noticeable foot odor? Yes No
Do you have a history of yeast infections? Yes No
Have you been "mouthed", scratched, or licked by an animal in the last 6 months? Yes No
Have you been bitten by mosquitoes or bugs? Yes No
Do you feel bloated, grumpy, or gassy after meals? Yes No
Have you eaten at a sushi bar, salad bar, or buffet recently? Yes No
Have you ever picked food up off the floor and eaten it? Yes No
Do you often crave sugar, sweets, or bread? Yes No
Do you experience anal itching? Yes No
Do you have dandruff? Yes No
Do you have indoor pets? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Hormone Balance

Are Your Adrenal Glands Functioning Properly?

If you answer "yes" to three or more questions, your adrenal system may be suffering.

Do you frequently feel "stressed out"? Yes No
Do you have difficulty falling asleep or maintaining sleep through the night? Yes No
Do sudden noises make you jump? Yes No
Do you become dizzy or light-headed when standing up too quickly? Yes No
Do you crave salt or sugar? Yes No
Do you drink coffee? Yes No
Have you taken any diet pills in the last 3 years? Yes No
Do you drink any highly caffeinated beverages such as soft drinks or energy drinks? Yes No
Do you exercise less than 3 times per week? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Is Your Thyroid Imbalanced?

If you answer "yes" to four or more questions, your thyroid may be imbalanced.

Are you frequently cold or do you have cold hands and feet? Yes No
Do you have trouble "getting going" in the morning? Yes No
Do you often feel sad or depressed, especially in the morning? Yes No
Are you unable to lose weight despite improving your diet and exercising more? Yes No
Do you have diffused or "patches" of hair loss from your head, arms, or legs? Yes No

What is your score? Add up the number of "yes" and "no" responses.

Are Your Sex Hormones Reduced in Production or Quality?

If you answer "yes" to two or more questions, your sex hormones may be low.

Are you "flabby" or have you experienced a loss of muscle tone? Yes No
Do you suffer from a low sex drive? Yes No
Do you frequently experience headaches or migraines? Yes No
Do you have Pre-Menstrual Syndrome (PMS)? Yes No

What is your score? Add up the number of "yes" and "no" responses.

For Women: Is Your Body Out of Balance?

If you answer "yes" to six or more questions, your body is out of balance!

Are you very easily fatigued? Yes No
Do you suffer from pre-menstrual syndrome? Yes No
Do you have painful menses (periods)? Yes No
Do you frequently experience depression before or during menstruation? Yes No
Is your menstrual cycle prolonged in duration or excessive in terms of blood flow? Yes No
Are your breasts overly sensitive or "painful" before, during, or after menses? Yes No
Do you menstruate too frequently (more than once per month or sporadic flow)? Yes No
Do you produce a vaginal discharge? Yes No
Have you had a hysterectomy or had your ovaries removed? Yes No
Do you have menopausal "hot flashes"? Yes No
Is your menses irregular or absent altogether? Yes No
Do you have acne or other skin blemishes that worsen during menses? Yes No
Have you felt depressed for 3 months or longer? Yes No
Do you have hair growth on your face or body? Yes No
Do you have or desire sex less than 2 times each month? Yes No

What is your score? Add up the number of "yes" and "no" responses.

For Men: Is Your Body Out of Balance?

If you answered "yes" to six or more questions, your body may be out of balance!

Are you very easily fatigued? Yes No
Do you experience premature ejaculation? Yes No
Is urination difficult or do you "dribble" i.e. can't stop completely? Yes No
Have you experienced or are you experiencing prostate trouble? Yes No
Do you often wake up during the night to urinate? Yes No
Do you have pain on the inside of your legs or heels? Yes No
Do you have feelings of incomplete bowel evacuation or "not emptying fully"? Yes No
Do you have problems sleeping? Yes No
Do you avoid even routine or mild physical activity? Yes No
Do you run out of energy during the day? Yes No
Do you experience leg nervousness or "twitching" at night? Yes No
Do you have difficulty falling asleep or maintaining sleep through the night? Yes No
Have you felt depressed for 3 months or longer? Yes No
Do you have or desire sex less than 2 times each month? Yes No

What is your score? Add up the number of "yes" and "no" responses.

†This questionnaire is not intended to diagnose, treat, cure, or prevent any disease. No statements herein have been evaluated by the FDA nor is any endorsement thereof implied or given. We advise use of this questionnaire simply as a starting point for gauging your overall health and wellness as a resource for further discussion with your healthcare provider.