Order Now! (210) 690-2770 BIOTOXICITY SYMPTOM QUESTIONNAIRE Rate each of the following symptoms based upon your typical health profile: POINT SCALE 0 - Never or almost never have the symptoms 1 - Occasionally has it, effect is not severe 2 - Occasionally has it, effect is severe 3 - Frequently has it, effect is not severe 4 - Frequently has it, effect is severe Once you submit us your health profile, we will add up the numbers to arrive at a total for each section, and then add the totals for each section to arrive at the grand total. If any individual section total is 10 or more, or the grand total is 25 or more, you may benefit from our detoxification program. NAME: required EMAIL: required PHONE: DIGESTIVE 0 1 2 3 4 Nausea or vomiting 0 1 2 3 4 Diarrhea 0 1 2 3 4 Constipation 0 1 2 3 4 Bloated feeling 0 1 2 3 4 Belching, passing gas 0 1 2 3 4 Heartburn EMOTIONS 0 1 2 3 4 Mood swings 0 1 2 3 4 Anxiety, fear, nervous 0 1 2 3 4 Anger, irritability 0 1 2 3 4 Depression EYES 0 1 2 3 4 Watery, itchy eyes 0 1 2 3 4 Swollen, reddened or sticky eyelids 0 1 2 3 4 Dark circles under eyes 0 1 2 3 4 Blurred/tunnel vision LUNGS 0 1 2 3 4 Chest congestion 0 1 2 3 4 Asthma, bronchitis 0 1 2 3 4 Shortness of breath 0 1 2 3 4 Difficulty breathing EARS 0 1 2 3 4 Itchy ears 0 1 2 3 4 Earaches, ear infection 0 1 2 3 4 Drainage from ear 0 1 2 3 4 Ringing in ears, hearing loss ENERGY/ACTIVITY 0 1 2 3 4 Fatigue, sluggishness 0 1 2 3 4 Apathy, sluggishness 0 1 2 3 4 Hyperactivity 0 1 2 3 4 Restlessness HEAD 0 1 2 3 4 Headaches 0 1 2 3 4 Faintness 0 1 2 3 4 Dizziness 0 1 2 3 4 Insomnia MIND 0 1 2 3 4 Poor memory 0 1 2 3 4 Confusion 0 1 2 3 4 Poor concentration 0 1 2 3 4 Poor coordination 0 1 2 3 4 Difficulty making decisions 0 1 2 3 4 Stuttering, stammering 0 1 2 3 4 Slurred speech 0 1 2 3 4 Learning disabilities MOUTH/THROAT 0 1 2 3 4 Chronic coughing 0 1 2 3 4 Gagging, need to clear throat 0 1 2 3 4 Sore throat, hoarse 0 1 2 3 4 Swollen or discolored tongue, gums, lips 0 1 2 3 4 Canker sores SKIN 0 1 2 3 4 Acne 0 1 2 3 4 Hives, rashes, dry skin 0 1 2 3 4 Hair loss 0 1 2 3 4 Flushing or hot flashes 0 1 2 3 4 Excessive sweating JOINT/MUSCLES 0 1 2 3 4 Pain or aches in joints 0 1 2 3 4 Arthritis 0 1 2 3 4 Stiff, limited movement 0 1 2 3 4 Pain, aches in muscles 0 1 2 3 4 Weakness or tiredness NOSE 0 1 2 3 4 Stuffy nose 0 1 2 3 4 Sinus problems 0 1 2 3 4 Hay fever 0 1 2 3 4 Sneezing attacks 0 1 2 3 4 Excessive mucus HEART 0 1 2 3 4 Skipped heartbeats 0 1 2 3 4 Rapid heartbeats 0 1 2 3 4 Chest pain WEIGHT 0 1 2 3 4 Binge eating/drinking 0 1 2 3 4 Craving certain foods 0 1 2 3 4 Excessive weight gain 0 1 2 3 4 Complusive eating 0 1 2 3 4 Water retention 0 1 2 3 4 Underweight OTHER 0 1 2 3 4 Frequent illness 0 1 2 3 4 Frequent/urgent urination 0 1 2 3 4 Genital itch, discharge Website Design by Ecoshop Network Wellness Life Center, Body-Tuning and Detoxification drroot@mydetoxkit.com