“How Toxic Am I?” Questionnaire

September 16, 2013



Do you consistently struggle with these symptoms?


Answer Yes or No.  (A ‘maybe’ is a Yes)


1. Energy Levels

2. Sugar and carb cravings

3. Sleep quality

4. Bowel movement regularity

5. Mood

6. Productivity

7. Clarity of thought

8. Hunger

9. Motivation

10. Skin-acne, rashes, rosacea, psoriasis

11. Gas, bloating, IBS

12. Sensitivity to smell

13. Joint pain

14. Headaches

15. Difficulty losing weight

16. Weight gain around the mid-line


What are your top 3 Detox Goals:








What are your top 3 Health Concerns:






Find Your Detoxification Ability Score

Please circle the appropriate response and add up your total DETOXIFICATION ABILITY score.


1. Bowel Movements

a. 1 daily, 4 or less days per week

b. 1 daily, at least 5 days a week

c. 1-2 a day


2. Sweating

a.  Consistently sweat 1 or less times a week

b.  Consistently sweat 2-3 times a week through exercise and/or sauna

c.  Consistently sweat 4 or more days a week through exercise and/or sauna


3. Water Intake

a.  I don’t drink water and/or I consume caffeinated beverages daily

b.  4-7 glasses of pure spring water daily and 1-2 servings of caffeinated beverages daily

c.  8 or more glasses of pure spring water per day and no more than 1 serving of caffeinated beverages daily.


4.  Fiber intake

 a.  Less than 10 grams per day (if you have no idea and you eat a diet high in processed, refined foods choose this)

b.  10-24 grams per day

c.  25 grams or more per day


5.  Digestion (gas, bloating, indigestion)

a.  Experience gas/bloating daily

b.  Experience gas/bloating 3/5 times a week

c.  Infrequently experience gas/bloating/indigestion – less than once a week


6.  Non-starchy vegetables, especially dark green and bright colored ones

a. Less than 2 servings daily

b.  2 or more servings daily

c.  5 or more servings daily


7.  Exercise

a.  Don’t exercise

b.  1-2 times per week

c.  3 or more times per week


8.  Sulfur rich foods (e.g. cabbage, broccoli, sprouts, eggs, onions)

a.  2 or less servings per week

b.  3-4 servings a week

c.  1 or more servings daily, 5 or more days per week


9.  Supplements (vitamins, minerals, antioxidants)

a.  None

b.  Daily use of a drugstore or grocery “one a day” type formula

c.  Daily use of professional brand multivitamin


10.  Probiotic Rich Foods & Supplements

a.  None

b.  Daily use of yogurt, infrequent use of probiotic supplement

c.  Daily use of naturally fermented foods and/or probiotic supplement



A = 1 point = poor

B = 2 points = average

C = 3 points = great


Total Detoxification Ability Score

The goal is to get as close to 30 as possible and to improve any areas in which you scored a 1.


Toxic Load Test

1.  Alcohol

a.  1 or less drinks per week

b.  2-4 drinks per week

c.  5+ drinks per week


2.  Caffeine

a.  None

b.  1-2 caffeinated drinks daily

c.  3+ servings daily


3.  Chemicals

a.  Live in a non-toxic living and work environment & don’t travel much or use dry cleaning

b.  Use organic cleansers/cleaning services & spend time where non-toxic sprays are used (parks, beaches, etc)

c.  Home and work place use non-organic cleaners


4.  Food

a.  Eat organic 90% of the time

b.  Eat organic 50% of the time

c.  Don’t eat much organic food or none


5.  Sugar, processed foods 7 artificial sweeteners/colorings

a.  I don’t eat anything with added sugar, artificial sweeteners or colors or processed foods

b.  I eat some things with sugar, etc.

c.  I eat foods with added sugar, etc. 5+ times a week or more


6.  Cooking

a.  I only use non-toxic glass, metal, non-stick or “safe” plastic containers (BPH free) and cooking tools

b.  I cook with non-stick pans (Teflon) or drink from plastic bottles a few times a week

c.  I cook with non-stick pans and/or drink from plastic bottles daily


7.  Smoking

a.  I don’t smoke & I’m not around second hand smoke

b.  I’m sometimes around second hand smoke or smoke infrequently

c.  I smoke or live with a daily smoker, or work in a smoky environment


8.  Silver Fillings

a.  I have no silver fillings

b.  I have 3 or less silver fillings, or have had them removed by a specially trained dentist

c.  I have 4+ silver fillings


9. Emotional

a.  I am easily able to express and handle my feelings and emotions

b.  I sometimes have a hard time managing my emotions

c.  I rarely/never share or release my emotions and feelings and keep them to myself


10.  Work

a.  I work in an environment that is nurturing, in a field/career that I am passionate about, and with people I get along with

b.  I usually enjoy what I do, I am indifferent about the field/career I am in, and I get along with some of the people I work with

c.  I dread going to work everyday, and/or I do not get along with the people I work with, and/or I do not enjoy the field/career I am currently in


A = 1 point = low

B = 2 point = low

C = 3 point = high


Total Toxicity Score:  

A total toxicity score of 26-30 is very high and immediate action is recommended.


Learn how to get lower your toxicity level with this signature program.  If you would like to apply for the scholarship program to get this program for free, contact me here.


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