Ask Kurt about the 21 Day Detoxification Diet
SYMPTOM SURVEY

The Toxicity Questionnaire is designed to aid the practitioner in assessing a persons potential need for a clinical purification program.

INSTRUCTIONS: Number the boxes which apply to you.

Please Use:

1
 for MILD symptoms (occur once or twice a year)
2
 for MODERATE symptoms (occur several times a year)
3
 for SEVERE symptoms (you are aware of it almost constantly).

You may notice that some questions are repeated in different sections. The reason for this is, the same symptoms can occur as a result of less than optimal function from different body systems/organs.

Sympathetic Nervous System

1 Acid foods upset 8 Gag easily 15 Appetite reduced
2 Get chilled, often 9 Unable to relax: startles easily 16 Cold sweats often
3 "Lump" in throat 10 Extremities cold, clammy 17 Fever easily raised
4 Dry mouth-eyes-nose 11 Strong light irritates 18 Neuralgia-like pain
5 Pulse speeds after meals 12 Urine amount reduced 19 Staring, blinks little
6 Keyed up - fail to calm 13 Heart pounds after retiring 20 Sour stomach frequent
7 Cuts heal slowly 14 "Nervous" stomach

Parasympathetic Nervous System

21 Joint stiffness after arising 28 Always seems hungry; feels "lightheaded" often 35 Difficulty swallowing
22 Muscle-leg-toe-cramps at night 29 Digestion rapid 36 Constipation, diarrhea alternating
23 "Butterfly" stomach, cramps 30 Vomiting frequent 37 "Slow starter"
24 Eyes or nose watery 31 Hoarseness frequent 38 Get "chilled" infrequently
25 Eyes blink often 32 Breathing irregular 39 Perspire easily
26 Eyelids swollen, puffy 33 Pulse slow; feels irregular 40 Circulation poor, sensitive to cold
27 Indigestion soon after meals 34 Gagging reflex slow 41 Subject to colds, asthma, bronchitis

Sugar Metabolism (Pancreas)

42 Eats when nervous 49 Heart palpitate if meals missed or delayed
43 Excessive appetite 50 Afternoon headaches
44 Hungry between meals 51 Overeating sweets upsets
45 Irritable before meals 52 Awaken after few hours of sleep - hard to get back to sleep
46 Get "shaky" if hungry 53 Craves candy or coffee in afternoon
47 Fatigue, eating relieve 54 Moods of depression - "blues" of melancholy
48 "Lightheaded" if meals delayed 55 Abnormal craving for sweets or snacks

Heart/Cardiovascular

56 Hands and feet go to sleep easily, numbness 63 Get "drowsy" often 69 "Nose bleeds" frequent
57 Sigh frequently, "air hunger" 64 Swollen ankles worse at night 70 Noises in head, or "ringing in ears"
58 Aware of "breathing heavily" 65 Muscle cramps, worse during exercise; get "charley horses" 71 Tension under breastbone, feeling of "tightness", worse on exertion
59 High altitude discomfort 66 Shortness of breath on exertion 72 Tendency to anemia
60 Opens windows in closed room 67 Dull pain in chest or radiating into left arm, worse on exertion
61 Susceptible to colds and fevers 68 Bruise easily, "black and blue" spots
62 Afternoon "yawner"

Liver/GB

73 Dizziness 82 Worrier, feels insecure 91 Sneezing attacks
74 Dry skin 83 Feeling queasy; headache over eyes 92 Dreaming, nightmare type bad dreams
75 Burning feet 84 Greasy foods upset 93 Bad breath (halitosis)
76 Blurred vision 85 Stools light-colored 94 Milk products causes distress
77 Itching skin and feet 86 Skin peels on foot soles 95 Sensitive to hot weather
78 Excessive falling hair 87 Pain between shoulder blades 96 Burning or itching anus
79 Frequent skin rashes 88 Use laxatives 97 Crave sweets
80 Bitter metallic taste in mouth in mornings 89 Stools alternate from soft to watery
81 Bowel movements painful or difficult 90 History of gallbladder attacks or gallstones

Digestion

98 Loss of taste for meat 103 Indigestion ½ -1 hour after eating; may be up to 3-4 hours
99 Lower bowel gas several hours after eating 104 Mucous colitis or "irritable bowel"
100 Burning stomach sensation, eating relieves 105 Gas shortly after eating
101 Coated tongue 106 Stomach "bloating" after eating
102 Pass large amounts foul-smelling gas

Thyroid

107 Insomnia 117 Increased appetite without weight gain 127 Sensitive to cold
108 Nervousness 118 Pulse fast at rest 128 Dry or scaly skin
109 Can't gain weight 119 Eyelids and face twitch 129 Constipation
110 Intolerance to heat 120 Irritable and restless 130 Mental sluggishness
111 Highly emotional 121 Can't work under pressure 131 Hair coarse, falls out
112 Flush easily 122 Increase in weight 132 Headaches upon rising wear off during day
113 Night sweats 123 Decrease in appetite 133 Slow pulse, below 65
114 Thin moist skin 124 Fatigue easily 134 Increased Frequency of urination
115 Inward trembling 125 Ringing in ears 135 Impaired hearing
116 Heart palpitates 126 Sleepy during day 136 Reduced initiative

Pituitary

137 Failing memory 144 Weight gain around hip or waist
138 Low blood pressure 145 Sex drive reduced or lacking
139 Increased sex drive 146 Tendency to ulcers, colitis
140 Headaches, "splitting or rending" type 147 Increased sugar tolerance
141 Decreased sugar tolerance 148 Women: menstrual disorders
142 Abnormal thirst 149 Young girls: Lack of menstrual function
143 Bloating of abdomen

Adrenal

150 Dizziness 158 Chronic fatigue 166 Swollen ankles
151 Headaches 159 Low blood pressure 167 Crave salt
152 Hot flashes 160 Nails weak, ridged 168 Brown spots or bronzing of skin
153 Increase blood pressure 161 Tendency to hives 169 Allergies-tendency to asthma
154 Hair growth on face or body (female) 162 Arthritic tendencies 170 Weakness after colds, influenza
155 Sugar in urine (no diabetes) 163 Perspiration increase 171 Exhaustion - muscular and nervous
156 Masculine tendencies (female) 164 Bowel disorders 172 Respiratory disorders
157 Weakness, dizziness 165 Poor circulation

Female Only Male Only
173 Very easily fatigued 186 Prostate trouble
174 Premenstrual tension 187 Urination difficult or dribbling
175 Painful menses 188 Night urination frequent
176 Depressed feelings before menstruation 189 Depression
177 Menstruation excessive and prolonged 190 Pain on inside of legs or heels
178 Painful breasts 191 Feeling of incomplete bowel evacuation
179 Menstruate too frequently 192 Lack of energy
180 Vaginal discharge 193 Migrating aches and pains
181 Hysterectomy/ovaries removed 194 Tire too easily
182 Menopausal hot flashes 195 Avoids activity
183 Menses scanty or missed 196 Leg nervousness at night
184 Acne, worse at menses 197 Diminished sex drive
185 Depression of long standing

Neurotransmitters Imbalance

198 Depression 204 Myoclonus 210 Compulsivity
199 Anxiety 205 Bipolar 211 Obsessionality
200 Panic attacks 206 Migraine Headaches 212 Impulsivity
201 Irritable bowel 207 Fibromyalgia 213 Self Injury
202 Insomnia 208 PMS 214 Obesity/Overweight

203 Aggression 209 Chronic pain

General

Ears Eyes Mind
Itchy ears Watery, itchy eyes Poor memory
Earaches, ear infections Swollen, reddened or sticky eyelids Confusion
Drainage from ear Dark circles under eyes Poor concentration
Ringing in ears, hearing loss Blurred / tunnel vision Poor coordination
Emotions Head Difficulty making decisions
Mood swings Headaches Stuttering, stammering
Anxiety, fear, nervousness Faintness Slurred speech
Anger, irritability Dizziness Learning disabilities
Depression Pressure Mouth / Throat
Sense of despair Lungs Gagging, frequent need to clear throat
Apathy / lethargy Chest congestion Swollen or discolored tongue, gums, lips
Energy / Activity Asthma, Bronchitis Canker sores
Fatigue / sluggishness Shortness of breath Nose
Hyperactivity Difficulty breathing Stuffy nose
Restlessness Chronic coughing Sinus problems
Insomnia Skin Hay fever
Startled awake at night Acne Sneezing attacks
Joint / Muscles Hives, rashes, dry skin Excessive mucous
Pain or aches in joints Hair loss Weight
Rheumatoid arthritis Flushing Binge eating / drinking
Osteoarthritis Excessive sweating Craving certain foods
Stiffness, limited movement Other Excessive weight
Pain, aches in muscles Frequent illness Compulsive eating
Recurrent back aches Frequent or urgent urination Water retention
Feeling of weakness or tiredness Leaky bladder Under weight
Genital itch, discharge

Food Choices

Check The Box If Your Answer Is "YES"

Do you eat sugar, candy, ice cream, baked goodies, etc?
Do you snack between meals and/or in the evening?
Do you consume "red" meat (beef, pork, lamb, venison, etc) more than 3 times per week?
Do you drink beverages with meals?
Do you eat more than 4 servings of cheese, yogurt, sour cream and/or ice cream per week?
Do you eat products made from soybeans more than once a week?
Do you drink more than 2 cans of soda pop per week?
Do you often consume items with NutraSweet(tm) / Aspartame(tm) in them?
Do you consume less than one cup of raw vegetables and one cup of raw fruits daily?
Do you consume more than 4 cups of dairy milk per week?
Do you try to eat a concentrated protein food (meat, fish, milk, cheese, eggs, nuts, seeds) at every meal?
Do you eat processed meats (wieners, sausage, pepperoni, baloney, etc)?
Do you eat more than 3 servings a week of white flour products (white bread, rolls, pasta, etc)?
Do you eat less than 3 servings per week of whole grain foods (whold wheat bread, brown rice, oatmeal, barley, etc)?
Do you regularly consume more than one of these foods in the same meal: meat, fish, cheese, egg, cereal, bread, pasta, rice, fruit/fruit juice, sweets?
Do you use salt or salted foods?
Do you consume "junk" foods and "junk" snacks regularly?
Do you skip breakfast?
Do you commonly eat late in the evening?
When you eat a meal, do you eat until you are stuffed?
Do you cook some of your food in a microwave oven?
Have you ever had a nutritional evaluation before?
Have you ever done a detoxification program before?
Have you ever done nutritional program?
Do you have any reason to believe that you may be pregnant?
Are you being treated for any health concerns by a physician? If so, what?
What medications/prescriptions have you taken in the last 3 years or are taking now? Please list all.
Are you currently taking any supplements? If so, what?
List any surgeries you have had:

Please list your 4 main health concerns in order of their priority

First Health Concern
Second Health Concern
Third Health Concern
Fourth Health Concern
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DISCLAIMER (Please Read) :

The educational information offered in the Symptom Survey is based solely on the indications provided by the client in their responses to the questions. The Symptom Survey is not a medical diagnosis. The information provided is drawn from several Doctors with more than 30 years of experience in the natural health field. This information is not a substitute for consulting a qualified health care practitioner. The client is advised to make use of the Symptom Survey Report judiciously on their own responsibility. There is no warranty regarding the results of using this information, and the author and publisher disclaim any liability for the actions of the client. These statements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure or prevent any disease. Nutritional advice, dietary supplements or other products are not offered to diagnose or prescribe for medical or psychological conditions nor to claim to prevent, treat, mitigate or cure such conditions, nor to recommend specific nutritional products as treatment of disease or to provide diagnosis, care, treatment or rehabilitation of individuals, or apply medical, mental health or human development principles. Your Symptom Survey and personal information will be forwarded to us. We will be processing it and will respond with your Symptom Survey results soon. So, keep checking your email for your exclusive confidential report. This is NOT a physician to patient service. If you are ready to submit your responses, other information, and have read and understand the above disclaimer, CLICK ON the "SUBMIT" button now.

 



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