i-Detox Client Intake Questionnaires
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The questionnaires below are intended for educational purposes only and are not a
replacement for primary care medical screening.
PART I: THE DETOX RISK QUESTIONNAIRE
How toxic might you be? How at risk are you? This part of the questionnaire
helps to identify your toxic exposures and generic risks to toxicity based on your
lifestyle and your body’s own detoxification efficiency. It takes time for our body to
show symptoms of toxic overload. The process of doing this questionnaire may raise
your awareness to your toxicity risk before your body shows symptoms. (Part II will
address symptoms)
A. Dietary Habits
a. How many serves of refined “white foods” (white bread, sweet breakfast
cereals, pasta, noodles, biscuits, pastries, cakes, white rice) do you eat
typically per day? (Scale: none = 0, one to two = 1, three to four = 2, five or
more = 3)
________
b. How many serves of red meat (not organic) do you consume per week?
(including beef, pork, lamb, bacon, sausages) (Scale: none = 0, organic
mostly less than five serves = 1, one to three = 1, three to six = 2, six to ten
= 3, more than ten = 4)
________
c. How many serves of poultry and diary (not organic) do you consume per
week? (including chicken, milk, egg) (Scale: none = 0, organic mostly less
than five serves = 1, one to three = 1, three to six = 2, six to ten = 3, more
than ten = 4)
________
d. How many total serves of fruits and vegetables do you consume per day?
(Scale: five or more = 0, four = 1, two to three = 2, one to two = 3, less
than one = 4)
________
e. I drink 7 to 8 glasses of liquid a day, not counting coffee or caffeinated
beverages. (Water requirement formula: weight in kg x 30-35ml) (Scale:
always = 0, less than that occasionally = 1, less than that half the time = 2,
less than that everyday = 3)
________
f.
I drink dehydrating beverages like coffee, tea or soda regularly. (Scale:
never or almost never = 0, one to two cups a day = 1, two to three cups a
day = 2, more than three cups everyday = 3)
________
g. I eat sugar (e.g. candies, chocolate, sugary drinks, sweetened cereals, etc)
or use artificial sweetener. (Scale: Never or almost never = 0, Yes = 1, I eat
something sugary all through the day = 2, I am addicted to sugar = 3)
________
Subtotal:________
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B. Toxic Exposure from Food and Water
a. What percentage of foods you eat is organic? (Scale: 100% = 0, 50% to
70% = 1, less than 50% = 2, less than 10% = 3)
________
b. How many serves of shellfish and local fish do you consume per week?
(Scale: none = 0, organic and deep water only less than five serves = 1, one
= 1, two to four = 2, five to seven = 3, more than seven = 4)
________
c. How often do you eat canned or frozen foods? (Scale: Rarely = 0, 5 to 7
times a month = 1, 3 – 7 times a week = 2)
________
d. How often do you eat foods containing MSG/artificial flavouring? (Scale:
Rarely = 0, less than 4 times a week = 1, more than 4 times a week = 2)
________
e. My liquid consumption is from unfiltered water (boiled or unboiled).
(Scale: Rarely = 0, 25% of the time = 1, 50% of the time = 2, Most of the
time = 4)
________
f.
I eat fast food and “junk food”. (Scale: Rarely = 0, two to three times per
week = 1, four to five times per week = 2, more than ten times per week =
3)
________
g. I eat fried foods, barbecued/burned foods or foods cooked with reused
vegetable oil. (Scale: Rarely = 0, two to three times per week = 1, four to
five times per week = 2, more than five times per week = 3)
________
Subtotal:________
C. Lifestyle Habits and Environmental Exposure
a. Your sleeping habit. Which describes you most? (Scale: a = 0, b = 1, c =
3, d = 4)
a. I regularly go to bed before 11pm and have adequate sleep.
b. I regularly go to bed between 12 to 2pm and have adequate
sleep.
c. I don’t go to bed at a regular time and I generally don’t sleep well.
d. I generally go to bed after 2pm and am sleep deprived.
________
b. How often do you breath fresh air or filtered air by a HEPA filter? (Scale:
Rarely = 0, 75% of the time = 1, 50% of the time = 2, 25% of the time = 3,
I am indoor most of the time and air is not filtered = 4)
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________
c. How often do you take prescription drugs or eat meat that contains
antibiotics? (Scale: Rarely = 0, Monthly = 1, Weekly = 2, Daily = 3, Daily &
heavily = 4, Daily meat consumption and antibiotics almost every year = 5)
________
d. How often do you drink alcohol? (Scale: Rarely = 0, 5 to 7 times a month =
1, 3 – 7 times a week = 2, More than two glasses of wine or equivalent
everyday = 3)
________
e. Do you smoke or are you exposed to second hand smoke? (Scale: Never =
0, Weekly or been in the past = 1, Daily = 2, Daily and severely = 3)
________
f.
How many mercury fillings do you have in your teeth? (Scale: None = 0,
Removed = 1, less than three = 2, more than three = 3, more than five = 4)
________
g. Are you exposed to cell phones, computers, remote control etc everyday?
(Scale: No = 0, Yes = 1, Yes and severely = 2)
________
h. Are you exposed to dry cleaned clothes, moth balls, fabric softener, fire
retardant, polyester and/or perm press chemical everyday? (Scale: No = 0,
Yes = 1, Yes and severely = 2)
i.
How often are you exposed to petrochemicals and bleaches? (e.g. household
cleaning products, skin care/cosmetics, female sanitary products)
(Scale: I use mostly organic and natural products = 0
About 50% of the products I use are organic = 1
About 30% to 50% of the products I use are organic = 2
None of the products I use are organic or chemical-free = 3)
________
j.
I live or work in an environment with treated wood/particle board and
conventional paint (Scale: No = 0, Yes = 1)
________
k. My work place or living place has been under renovation in the past year.
(Scale: No = 0, Yes = 1, Both = 2)
________
l.
I am exposed to foam pillows, mattresses or sofas daily. (Scale: No = 0, Yes
= 1)
________
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i-Detox Client Intake Questionnaires
m. I use foam or plastic food containers daily and I use them for heated
beverages or food. (Scale: No = 0, Yes but not with heat = 1, Daily and with
heat = 2)
________
n. I am exposed to soft plastic disposable water bottle and clear plastic food
wrap daily. (Scale: No = 0, Yes = 1)
________
o. I am exposed to mostly incandescent or fluorescent light and rarely get
natural light or full spectrum light exposure. (Scale: No = 0, Yes = 1)
________
Subtotal:________
D. How is your elimination system detoxifying?
1. Bowel Movements (Scale: a = 0, b = 1, c = 3, d = 4)
a. I have regular, well formed soft-bowel movements 2 to 3 times a
day.
b. I have one bowel movement a day.
c. I have hard, difficult-to-pass movements once a day or once every
other day.
d. I am constipated and only go every other or less often.
________
2. Urination (Scale: a = 0, b = 1, c = 3, d = 4)
a. I urinate large volumes of clear light yellow urine regularly
throughout the day.
b. I urinate moderate amounts of yellow coloured urine 3-4 times a
day.
c. I urinate small amount of dark, strong smelling urine a few times
a day.
d. I urinate very dark and strong smelling urine once or twice a day.
________
3. Sweating (Scale: a = 0, b = 1, c = 3, d = 4)
a.
b.
c.
d.
I
I
I
I
sweat easily and daily through exercise or saunas or hot baths.
sweat profusely 2 – 3 times a week.
sweat lightly a few times a week.
don’t sweat easily and almost never break a sweat.
________
Subtotal:________
E. Do you have a personal or family history of… (Scale 0 = No, 1 = Yes)
a. Breast cancer
________
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b.
c.
d.
e.
f.
g.
Smoking-induced lung cancer
________
Other type of cancer
________
Prostate cancer
________
Food allergies, sensitivities, or intolerances
________
Environmental sensitivities
________
Parkinson’s, Alzheimer’s or other motor neuron disease, or multiple
sclerosis
________
h. Asthma
________
i. Lupus, rheumatoid arthritis or other autoimmune disease
________
Subtotal:________
Grand total: ________
Interpreting Your Toxicity Score:
Total 25 or lower: You have a low overall risk for problems relating to impaired
detoxification.
Total 26 to 50: You detoxification system is at minimal to average risk. Doing the
i-Detox 9-Day program at least once a year would be beneficial to you.
Total 51 to 85: You are at significant risk for diseases and symptoms related to
impaired detoxification. You may benefit from the i-Detox 9-Day program two to
three times a year.
Total 85 or above: You show a high risk to toxicity and likely need further testing
and medical supervision for a prolonged detoxification.
Proceed to Part II to take a more detailed assessment of your possible
toxic load based on your symptoms.
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i-Detox Client Intake Questionnaires
Part II: TOXICITY QUESTIONNAIRE
Everyone person’s experience of symptoms is different. This questionnaire gives an
indication of your toxicity level based on common symptoms related to toxicity and is not
intended as a medical screening.
Take this before and after your detox program.
success of your detox efforts.
It will help you to monitor the
Rate each of the following symptoms based upon your health profile for the past
30 days.
POINT SCALE:
0 = Never or almost never have the symptom
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
DIGESTIVE
TRACT
EARS
EMOTIONS
ENERGY
EYES
HEAD
HEART
JOINT/MUSCLES
_____
_____
_____
_____
_____
_____
_____
Nausea or vomiting
Diarrhea or watery motions
Constipation (less than one BM daily)
Bloated feeling
Belching, or passing gas
Intestinal/stomach pain
Heartburn, indigestion
_____
_____
_____
_____
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss
Total: _____
_____
_____
_____
_____
Mood swings
Anxiety, fear or nervousness
Anger, irritability, or aggressiveness
Depression
Total:_____
_____
_____
_____
_____
Fatigue/sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total:_____
_____
_____
_____
_____
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Total: _____
(does not include near- or far-sightedness)
Total:_____
_____
_____
_____
_____
Total:_____
Headaches
Faintness
Dizziness
Insomnia
_____ Irregular or skipped heartbeat
_____ Rapid or pounding heartbeat
_____ Chest pain/blocked arteries
_____
_____
_____
_____
Pain or aches in joints or lower back
Arthritis
Stiffness or limitation of movement
Pain or aches in muscles
Total:_____
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i-Detox Client Intake Questionnaires
_____ Feeling of weakness or tiredness
LUNGS
Total:____
_____
_____
_____
_____
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
MIND
_____
_____
_____
_____
_____
_____
_____
Poor memory
Foggy headedness, poor comprehension
Poor concentration
Poor physical coordination
Difficulty in making decisions
Stuttering or stammering or slurred speech
Difficulty in learning
Total: _____
MOUTH/
THROAT
_____
_____
_____
_____
_____
_____
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Coated tongue, or discoloured gums, lips
Swollen lymph glands
Canker sores, mouth ulcers
Total:_____
NOSE
_____
_____
_____
_____
_____
Itchy nose
Stuffy nose
Sinus problems
Hay fever/Sneezing attacks
Excessive mucus formation
SKIN
_____
_____
_____
_____
_____
_____
_____
_____
Acne or red spots on face or body parts
Brown “age/liver spots” on hands or face
Hives, rashes, or eczema
Flushing or hot flashes (not related to menopause)
Body odour
Hair Loss
Greasy skin
Excessive sweating
Total:_____
WEIGHT
_____
_____
_____
_____
_____
_____
Compulsive eating or drinking
Cravings certain foods
Overweight
Difficulty to lose weight (weight doesn’t shift)
Water retention
Underweight, poor appetite
Total:_____
OTHER
_____
_____
_____
_____
_____
Frequent illness or long recovery time
Recreational drug cravings (including tobaaco and alcohol)
Frequent or urgent urination
Genital itch or discharge
(For female only) Heavy periods
Total:_____
Total:_____
Total:_____
GRAND TOTAL :
_____
Interpreting Your Toxicity Score:
Total 10 or lower: Congratulations! Your sign of toxicity is low. You may continue
your lifestyle and use the i-Detox 9-Day program without the Liver Flush once a year for
maintenance.
Total 11 to 20: You are showing mild level of toxicity. You may use the i-Detox 9Day program once to twice a year.
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Total 21 – 40: You are showing mild to moderate level of toxicity. You may use
the i-Detox 9-Day program two to three times a year.
Total 41 – 80: You are showing moderate to high level of toxicity. You can benefit
from our detox program and may extend it to two weeks or longer, and repeat again in a
year, depending on your post detox score. You may also be suffering from some food
intolerances. Food allergy test and treatment may be considered. You are advised to see a
health professional experienced with allergies and detoxification.
Total 80 or above: You are showing signs of severe toxicity. While this program will
be beneficial to you and is best to be extended beyond 9 days, you may need to address
other health issues before starting the detox program. Consultation with an experienced
professional is highly recommended.
MEDICAL DISCLAIMER
About the i-Detox program:
While this program is designed to be safe to use for most people, you are recommended to
see your health care provider and make sure you don’t have any contraindications for
following the program.
Do not do this program if you are:
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Pregnant
Breastfeeding
Recovering from a recent operation
Below the age of 18 or above 60 (consult a professional to customize a
program for you)
Do not undertake this program without medical supervision if you are
suffering from:
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Alzheimer’s and Dementia
Arthritis
Autoimmune Diseases (eg AIDS, Lupus, Celiac disease)
Blood Pressure issues (High or Low)
Cancer
Chronic Fatigue Syndrome
Depression
Diabetes
Epilepsy
Fibromyalgia
Food Allergies
Headaches and migraines
Heart Disease
Inflammatory Bowel Disease (Crohn’s or Ulcerative Colitis)
Infections including Candida
Kidney failures
Liver failures
Low Blood Sugar (e.g. prone to sudden tiredness, irritability, strong sugar and
caffeine cravings)
Menopausal Symptoms (e.g. mood changes, poor sleep, hot flashes)
Mental Illnesses
Serious Addictions (e.g. alcohol, drugs, caffeine)
Underweight (10 lbs or more)
The information contained in this document is intended for educational purposes only. It is not
intended to diagnose or treat any disease, illness or injury. Neither i-Detox nor the author accepts
responsibility for such use.