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Before You Detox

Before you begin the Core Restore detoxification program, it is important to first evaluate your current health state. This questionnaire will help identify signs of toxic burden. You will take this questionnaire again after your detox program to evaluate your progress. This will help you and your healthcare provider evaluate your success and continued improvement.

Fill Out Your Toxic Burden Questionnaire 

Section 1: Symptoms

POINT SCALE:      0 = Never      1 = Occasionally      2 = Frequently

Please add the totals from each section and write the section total in the spaces provided. Then, add all the section totals together and put that total in the space below.

Digestive
Bowel movements less than once per day
Bloated feeling
Belching and/or gas
Heartburn
Ears
Itchy ears
Earaches
Drainage from ear
Ringing in ears and/or hearing loss
Skin
Acne
Hair loss and/or hair thinning
Body odor
Excessive sweating
Head
Headaches
Pressure
Dizziness
Faintness
Emotions
Mood swings
Feelings of fear and/or nervousness
Anger and/or irritability
Feelings of sadness
Eyes
Watery and/or itchy eyes
Swollen and/or reddened eyelids
Dark circles under the eyes
Blurred vision (excluding near- or far-sightedness)
Nose
Stuffy nose
Sinus congestion
Sneezing
Mucus
Joints & Muscles
Pain or aches in joints and/or lower back
Stiffness and/or limitation in movement
Pain or aches in muscles
Feelings of weakness and/or tiredness
Heart
Skipped heartbeats
Rapid heartbeats
Chest discomfort
Lungs
Shortness of breath
Difficulty breathing
Chest congestion
Mind
Poor memory and/or confusion
Difficulty concentrating
Poor coordination
Difficulty making decisions
Weight
Underweight
Overweight
Difficulty losing weight
Crave certain foods
Energy & Activity
Fatigue and/or sluggishness
Hyperactivity
Restlessness
Occasional sleeplessness
Mouth & Throat
Coughing
Gagging and/or frequent need to clear throat
Hoarseness and/or loss of voice
Dental problems
Other
Food sensitivities
Chemical and/or environmental sensitivities
Frequent and/or urgent urination
Bloating and/or mood swings before menstruation

Please add the totals from each section and write the section total in the spaces provided. Then, add all the section totals together and put that total in the space below.

INTERPRETING YOUR TOXIC LOAD SCORE:
SELECT THE OPTION THAT ALIGNS WITH YOUR TOXIC BURDEN SCORE:

Section 2: Risk of Exposure

RATING SCALE:     

0 = NO, Never      1 = Yes, but not in the past year

2 = Yes, intermittent in the last year 3 = Yes, currently or ongoing

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Rate each of the following based on your environmental exposure.

Heavy Metal Exposure:
Do you live in a home that has plumbing pipes or fixtures installed before 1986?
Do you use unfiltered water for drinking and cooking?
Do you have root canals, extracted teeth, dental implants, “silver” fillings, crowns, dental sealants, dentures or braces?
Do you eat seafood (including farmed seafood)?
Do you consume canned foods?
Do you live or work around exhaust fumes, tobacco smoke, cleaning chemicals, paint or other volatile fumes?
Mycotoxin Exposure
Do you live or work in an area with signs of mold or water damage (e.g., cracking paint, ceiling leaks, decaying insulation or foam, visible mold, or damp areas in windows, crawlspaces, or basements)?
Do you drink water from a well or cistern?
Do you consume nuts, grains, beans, seeds, coffee, sugar, dried fruit or hard cheeses that have been stored for a prolonged period or in warm or humid conditions?
Common Food Exposure:
Do you eat conventionally farmed (non-organic) or genetically modified fruits and vegetables?
Do you eat conventionally raised (non-organic) animal products (e.g., meat, poultry, dairy or eggs)?
Do you eat processed foods (e.g., foods with added artificial colors, flavors or preservatives)?
Do you live or work in an agricultural or other area where you are exposed to pesticides, herbicides or fungicides?
Do you consume tofu?
Hormone-Altering Exposures:
Do you use the microwave to prepare prepackaged meals or reheat food in Styrofoam or other non-ceramic or non-glass containers?
Do you drink beverages from plastic bottles?
Do you use nonstick Teflon pans for cooking in your home?
Are you taking hormone replacement therapy (including bioidentical hormone therapy)?
Other Exposures:
Do you have food reactions, sensitivities or intolerances?
Do you drink sodas, juices or other beverages with refined or artificial sweeteners?
Do you eat deep-fried or fast foods?
Do you take any over-the-counter (acetaminophen, ibuprofen, naproxen, etc.) or prescriptive medications (antibiotics, opioids, etc.)?
Do you lead a high-stress lifestyle or have prolonged exposure to mental or emotional stress?

Please share your risk of exposure ratings with your provider.

This is a screening tool and not a diagnostic tool. The purpose of this questionnaire is to help determine an association between symptoms and potential toxic burden.

Thanks for submitting!

This is a screening tool, and not a diagnostic tool. The purpose of this questionnaire is to help determine an association between symptoms and potential toxic burden.

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