Print This PageUse 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!
General Health Questionnaire
Instructions
- Print a copy of this questionnaire.
- Circle yes or no to answer the questions.
- Fill in your score where indicated.
- 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 feel basically healthy?
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?Do you feel basically healthy?
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?Do you feel basically healthy?
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
Do you feel basically healthy?
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?Do you feel basically healthy?
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 answered "yes" to six or more questions, your body may be out of balance!
Are you very easily fatigued?
Yes
No
Do you feel basically healthy?
Yes
No
Do you feel basically healthy?
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.