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Toxic Screen

09 Sep, 2020

Welcome to your Toxic Screen

Weight Information

Are you happy with your weight?

Have you always been overweight?
How do you feel about your weight?
How have you felt about your weight in the past?

Are you prepared to reshape your lifestyle to achieve your health and weight goals?

Painful and/or lumpy breasts?
Cyclical headaches?
Infertility?

SECTION 1
Detoxification

HEAD

Headaches?
Faintness?
Dizziness?
Insomnia​​?
Not at all
Some symptoms?
Regular problems?

Debilitating situation?

EYES

Watery or itchy eyes?
Swollen, reddened or sticky eyelids?
Bags or dark circles under eyes?
Blurred or tunnel vision?
Weight Information

Are you happy with your weight

EARS

Itchy ears?
Earaches, ear infections?
Drainage from ear?
Ringing in ears, hearing loss?

About You

Your new question!
How many times a day do you eat pasta, rice, pastries, croissants, cakes, biscuits, pizzas, bread, cereals, rolls?

NOSE​

Stuffy nose?

Sinus problems?

Hay fever?

Sneezing attacks?

Mouth?

MOUTH

Chronic coughing?




Throat?

THROAT

Gagging, frequent need to clear throat?
Sore throat, hoarseness, loss of voice?
Swollen or discolored tongue, gums, lips?
Canker sores​​?

SKIN​

Acne?

Hive, rashes, dry skin?
Hair loss?
Full Name

Flushing, hot flushes?
Excessive sweating​?

HEART​

Chest pain?

Irregular or skipped heartbeat?
Rapid or pounding heartbeat?

LUNGS

Chest congestion?

Asthma, bronchitis?
Shortness of breath?
Difficulty breathing?

DIGESTIVE TRACT

Nausea, vomiting?

Diarrhea?
Constipation?
Bloated feeling?

Belching, passing gas?

Heartburn?
Intestinal / stomach pain?

JOINTS/​MUSCLE

Pain or aches in joints?

Arthritis?
Stiffness or limitation of movement?
Feeling of weakness or tiredness?
Pain or aches in muscles?

WEIGHT

Binge eating/drinking?

Craving certain foods?
Excess weight?
Water retention?

Underweight?

Compulsive eating?

ENERGY/ ACTIVITY

Fatigue, sluggishness?

Apathy, lethargy?
Hyperactivity?
Restlessness?

MIND

Poor memory?

Confusion, poor comprehension?

Difficulty in making decisions?
Stuttering or stammering?
Slurred speech?
Learning disabilities?
Poor concentration?
Poor physical coordination?

EMOTIONS

Mood swings?

Anxiety, fear, nervousness?
Anger, irritability, aggressiveness?
Depression​​?
Energy?

OTHER

Frequent illness?

Frequent or urgent urination?
Genital itch or discharge?
Regular colds and infections?
Frequent bouts of depression?
How often do you exercise?

SECTION 3

Tobacco

​Do you currently smoke cigarettes?

Caffeine use

Do you consume drinks with caffeine (coffee, tea, soda drinks)?

Alcohol and Drugs

Do you drink alcohol?​​​​​​

Do you consume drugs?

Hormone Balance Test For Men

SYMPTOM GROUP 1

Weight loss?

SECTION 2

Exercise

Do you consider your exercise habits to be?

Have you always been overweight?
How do you feel about your weight?
How have you felt about your weight in the past?
Are you prepared to reshape your lifestyle to achieve your health and weight goals?
Height
Weight

ADDITIONAL WEIGHT INFORMATION 

Are you happy with your weight?

Have you always been overweight?

How old are you?

Height
Weight
Weight