General Health Questionnaire

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Use this Questionnaire to gauge your progress before and after cleansing.†

Fill this out before and 3 days after your first cleanse, and 3 days after your last cleanse.

Please let us know your results we love to hear from our customers!

Instructions:

  1. Print a copy of this questionnaire.
  2. Circle YES or NO to answer the questions.
  3. Fill in Your Score where indicated.
  4. Save this questionnaire to compare your results from before and after cleansing.

Today's Date: ______________________

Overall Well-Being

Consider Your Current Symptoms and Overall Sense of Well-Being and Answer:

  • Do You Feel Basically Healthy?
  • Do You Consider Yourself Happy?
  • Yes No
  • Yes No

List any negative health symptoms you're experiencing:

 

 

 

 

 

 

Do You Have Chronic Inflammation in Your Body?

If You Answer 3 or More Questions "YES" You May Have Chronic Inflammation.

  • Do you have elevated cholesterol or triglycerides?
  • Do you have numbness or tingling in your arms or legs?
  • Do you eat meat, commercially baked sweets, fried foods, or use vegetable oil daily?
  • Do you consume fish less than two times per week?
  • Do you have high blood pressure, asthma, or colitis?
  • Do you smoke?
  • Do you have gingivitis, periodontal disease, or not have regular dental cleansings and check-ups at least once every six months?
  • Yes No
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  • Yes No

What is your score? Add up the number of "YES" and "NO" responses.

Poor Nutrition and Lifestyle

Do You Have Poor Nutrition and Digestion?

If You Answer 4 or More Questions "YES" You May Have Poor Nutrition and Digestion.

  • Do you regularly include fast food in your diet (three or more times per week)?
  • Do you experience belching, bloating, or persistent fullness soon after eating, or do you experience excess gas often?
  • Do you experience heartburn or acid reflux two or more times per week?
  • Are you allergic to any specific foods?
  • Do you feel fatigued or lethargic after eating?
  • Do you commonly have bad breath or a bad taste in your mouth?
  • Do you use digestive aids such as laxatives, antacids, or acid-blocking drugs?
  • Do you often feel "older" than you should for your age?
  • Does your skin look sallow, gray, puffy, wrinkled, or aged?
  • Yes No
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  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

Do You Have Abnormal Blood Sugar Levels? Are You Pre-Diabetic or At Risk?

If You Answer 3 or More Questions "YES" You Could Have Abnormal Blood Sugar Levels.

  • Does your waistline extend beyond your hips or are you overweight?
  • 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?
  • Do you eat dried beans e.g. pinto, navy, black, etc. less than three times per week?
  • Do you exercise less than three times each week?
  • Do you eat two or more servings of bread, pasta, candy, colas, or fruit juice a day?
  • Do you eat fewer than five servings of fresh, raw vegetables and fruits per day?
  • Do you have high blood triglyceride levels or suffer from hypertension?
  • Yes No
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  • Yes No
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  • Yes No

What is your score? Add up the number of "YES" and "NO" responses.

Do You Have Impaired Cellular/Mitochondrial Function?

If You Answer 3 or More Questions "YES" You May Have Impaired Cellular Function.

  • Are you frequently tired for no reason (especially around 3 P.M.)?
  • Do you have stiff and sore muscles (unrelated to recent exercise)?
  • Do you have poor stamina, shortness of breath, or feel exhausted after exercising?
  • Do you exercise less than two hours per week?
  • Have you ever been diagnosed with iron deficiency or do you have heavy menses?
  • Do you look older than your true age?
  • Have you ever been exposed to toxic chemicals or heavy metals?
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • 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 4 or More Questions "YES" Your Body Needs Help to Detoxify.

  • Do you become physically ill when exposed to strong smells (perfume, auto-exhaust, cigarette smoke, etc.)?
  • Do you use chemical cleaners or solvents at home, at work, or in your hobbies?
  • Do you live in a house/apartment or work in an office less than 5 years old?
  • Do you have any amalgam (mercury) dental fillings?
  • 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)?
  • Do you have fewer than 2 bowel movements daily?
  • Do you smoke?
  • Do you have or have you ever had breast implants?
  • Do you have any pets, especially dogs, cats, birds, or other furred or feathered animals?
  • Do you wake up often during the night to urinate?
  • Yes No
  • Yes No
  • Yes No
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  • Yes No
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  • Yes No
  • Yes No
  • Yes No

What is your score? Add up the number of "YES" and "NO" responses.

Is Your Home and/or Work Environment Toxic?

If You Answer 4 or More Questions "YES" Your Home or Office Needs a "Health Makeover."

  • Do you have carpet in your home?
  • Do you vacuum less than 3 times per week?
  • Have you changed or cleaned your air filters in the last 30 days?
  • Do you routinely drink tap water?
  • Are your clothes and bedding washed in unfiltered city water?
  • Have you recently repainted your home on the inside?
  • Have you noticed any black spots or mold on your air vents or walls?
  • Have you had your air vents cleaned in the past year?
  • Do you use chemical based cleaners in your home?
  • Do you use chemical fertilizers, insecticides, or pesticides?
  • Yes No
  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

Impaired Immune System

What is the Quality of Your Immune System Function?

If You Answer 4 or More Questions "YES" Your Immune System May be Overworked.

  • Do you catch colds or the flu easily?
  • Do colds, flu, or other infections tend to linger in your system more than 5 days?
  • Do you have a chronic cough, scratchy throat, sinus congestion, or excess mucous production making it necessary to clear your throat often?
  • Do you have seasonal allergies or known allergies to dust, animals, or mold?
  • Have you ever been diagnosed with an autoimmune disease?
  • Do you have dark circles under your eyes?
  • Do you have difficulty seeing at night, or do you have white spots on your fingernails?
  • Have you recently had any vaccinations?
  • Have you or anyone in your family served in the military in the last 15 to 20 years?
  • Yes No
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  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

Is Your Liver Impaired by Your Emotions?

If You Answer 5 or More Questions "YES" Your Liver May Be Impaired.

  • Do you feel angry from time to time?
  • Are you agitated easily?
  • Do you have frequent mood swings?
  • Is it hard to stay in a good mood?
  • Do you run out of energy during the day?
  • Do you have brown spots on your skin or age spots?
  • Does your skin break out or is it blemished?
  • Are your emotions often on a "roller coaster"?
  • Do you later have to apologize for your bad moods to friends, family, co-workers, etc.?
  • Is there always "something wrong" in your life?
  • Have you ever been physically or sexually abused?
  • If you are upset, is it best not to talk to you about what's going on?
  • Do you get annoyed by the "fake" cheeriness of others?
  • Do these questions irritate you?
  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

Are Your Kidney and Urinary Systems Functioning Properly?

If You Answer 5 or More Questions "YES" Your Kidneys May Be Overworked.

  • Do you have pain in your muscles and joints?
  • Have you had kidney or bladder infections in the last year?
  • Have you experienced ankle pain or swelling in the last year?
  • Do you have left shoulder pain?
  • Do your fingernails chip or break easily?
  • Do you have puffiness, "bags", or dark circles under your eyes?
  • Is your hair thinning?
  • Do you have frequent scalp irritations?
  • Do you have painful, harsh menstrual cycles?
  • Do you wake up often during the night to urinate?
  • Do you feel exhausted in the morning even after sleeping 8 or more hours?
  • Have you ever been diagnosed with thyroid problems?
  • Yes No
  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

Do You Have Parasites, Viruses, Fungi, or other Microbes Inside Your Body?

If You Answer 4 or More Questions "YES" You May Need a Thorough Parasite Cleanse.

  • Do you have any yellowish discoloration on your fingernails or toenails?
  • Do you have athlete's foot or noticeable foot odor?
  • Do you have a history of yeast infections?
  • Have you been "mouthed", scratched, or licked by an animal in the last 6 months?
  • Have you been bitten by mosquitoes or bugs?
  • Do you feel bloated, grumpy, or gassy after meals?
  • Have you eaten at a sushi bar, salad bar, or buffet recently?
  • Have you ever picked food up off the floor and eaten it?
  • Do you often crave sugar, sweets, or bread?
  • Do you experience anal itching?
  • Do you have dandruff?
  • Do you have indoor pets?
  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

Hormonal Imbalance

Are Your Adrenal Glands Functioning Properly?

If You Answer 3 or More Questions "YES" Your Adrenal System May Be Suffering.

  • Do you frequently feel "stressed out"?
  • Do you have difficulty falling asleep or maintaining sleep through the night?
  • Do sudden noises make you jump?
  • Do you become dizzy or light-headed when standing up too quickly?
  • Do you crave salt or sugar?
  • Do you drink coffee?
  • Have you taken any diet pills in the last 3 years?
  • Do you drink any highly caffeinated beverages such as soft drinks or energy drinks?
  • Do you exercise less than 3 times per week?
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
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  • Yes No
  • Yes No
  • Yes No

What is your score? Add up the number of "YES" and "NO" responses.

Is Your Thyroid Imbalanced?

If You Answer 4 or More Questions "YES" Your Thyroid May Be Imbalanced.

  • Are you frequently cold or do you have cold hands and feet?
  • Do you have trouble "getting going" in the morning?
  • Do you often feel sad or depressed, especially in the morning?
  • Are you unable to lose weight despite improving your diet and exercising more?
  • Do you have diffused or "patches" of hair loss from your head, arms, or legs?
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • 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 2 or More Questions "YES" Your Sex Hormones May Be Reduced.

  • Are you "flabby" or have you experienced a loss of muscle tone?
  • Do you suffer from a low sex drive?
  • Do you frequently experience headaches or migraines?
  • Do you have Pre-Menstrual Syndrome (PMS)?
  • Yes No
  • Yes No
  • Yes No
  • 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 Answer 6 or More Questions "YES" Your Body is Out of Balance!

  • Are you very easily fatigued?
  • Do you suffer from Pre-Menstrual Syndrome (PMS)?
  • Do you have painful menses (periods)?
  • Do you frequently experience depression before or during menstruation?
  • Is your menstrual cycle prolonged in duration or excessive in terms of blood flow?
  • Are your breasts overly sensitive or "painful" before, during, or after menses?
  • Do you menstruate too frequently (more than once per month or sporadic flow)?
  • Do you produce a vaginal discharge?
  • Have you had a hysterectomy or had your ovaries removed?
  • Do you have menopausal "hot flashes"?
  • Is your menses irregular or absent altogether?
  • Do you have acne or other skin blemishes that worsen during menses?
  • Have you felt depressed for 3 months or longer?
  • Do you have hair growth on your face or body?
  • Do you have or desire sex less than 2 times each month?
  • Yes No
  • Yes No
  • Yes No
  • Yes No
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  • Yes No
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  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

FOR MEN - Is Your Body Out of Balance?

If You Answered 6 or More Questions "YES" Your Body May Be Out of Balance!

  • Are you very easily fatigued?
  • Do you have premature ejaculation?
  • Is urination difficult or do you "dribble" i.e. can't stop completely?
  • Have you experienced or are you experiencing prostate trouble?
  • Do you often wake up during the night to urinate?
  • Do you have pain on the inside of your legs or heels?
  • Do you have feelings of incomplete bowel evacuation or "not emptying fully"?
  • Do you have problems sleeping
  • Do you avoid even routine or mild physical activity?
  • Do you run out of energy during the day?
  • Do you experience leg nervousness or "twitching" at night?
  • Do you have difficulty falling asleep or maintaining sleep through the night?
  • Have you felt depressed for 3 months or longer?
  • Do you have or desire sex less than 2 times each month?
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
  • Yes No
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What is your score? Add up the number of "YES" and "NO" responses.

†Note — This General Health 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 consideration of any negative health symptoms you may be experiencing and potential preventative measures or as a resource for further discussion with your healthcare provider.

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