2280 East Avenue, Suite 4, Rochester, New York 14610, United States
Key to Questionnaire
Optimal Health: less than 10
Mild Toxicity: 10 to 50
Moderate Toxicity: 50 to 100
Severe Toxicity: over 100
Digestive Tract
____ Nausea or vomiting
____ Diarrhea
____ Constipation
____ Bloated Feeling
____ Belching or passing gas
____ Heartburn
____ Intestinal, stomach pain
Total ___________
Ears
____ Itchy ears
____ Earaches, ear infection
____ Drainage from ear
____ Ringing in ears, hearing loss
Total ___________
Emotions
____ Mood swings
____ Anxiety, fear or nervousness
____ Anger, irritability or aggressiveness
____ Depression
Total ___________
Eyes
____ Watery or itchy eyes
____ Swollen, reddened or sticky eyelids
____ Bags or dark circles under eyes
____ Blurred or tunnel vision (does not include near or farsightedness)
Total ___________
Head
____ Headaches
____ Faintness
____ Dizziness
____ Insomnia
Total ___________
Heart
____ Irregular or skipped heartbeat
____ Rapid or pounding heartbeat
____ Chest pain
Total ___________
Joints/Muscles
____ Pain or aches in joints
____ Arthritis
____ Stiffness or limitation of movement
____ Pain or aches in muscles
____ Feeling of weakness or tiredness
Total ___________
Lungs
____ Chest congestion
____ Asthma, bronchitis
____ Shortness of breath
____ Difficulty breathing
Total ___________
Mind
____ Poor memory
____ Confusion, poor comprehension
____ Poor concentration
____ Poor physical coordination
____ Difficulty in making decisions
____ Stuttering or stammering
____ Slurred speech
____ Learning disabilities
Total ___________
Mouth/Throat
____ Chronic coughing
____ Gagging, frequent need to clear throat
____ Sore throat, hoarseness, loss of voice
____ Swollen or discolored tongue, gums or lips
____ Canker sores
Total ___________
Nose
____ Stuffy nose
____ Sinus problems
____ Hay fever
____ Excessive mucus formation
____ Sneezing attacks
Total ___________
Skin
____ Acne
____ Hives, rashes or dry skin
____ Hair loss
____ Flushing or hot flashes
____ Excessive sweating
Total ___________
Weight
____ Binge eating/drinking
____ Craving certain foods
____ Excessive weight
____ Compulsive eating
____ Water retention
____ Underweight
Total ___________
Other
____ Frequent illness
____ Frequent or urgent urination
____ Genital itch or discharge
Total ___________
Grand Total __________
Source: The 10-Day Blood Sugar Solution Detox Diet, Dr. Mark Hyman
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