Wufoo

Nutrition Northwest Detox Questionnaire

Get the down and dirty on your toxic levels by taking our quick questionnaire!
**Please enter your contact information at the bottom of this form. If you do not offer your email I cannot reply with an assessment. Your email does not appear when you click 'submit' Thank you!

How often do you experience indigestion?

A). Rarely B). Monthly C). Weekly or more
How often do you take prescription medication or over the counter medication (antacids, aspirin, etc)?
A). Never or (Rarely) B). Monthly C). Weekly
How often do you experience belching/ flatulence?

A). Never or (Rarely) B). Weekly C). Daily
How often do you have dry and tired eyes?

A). Never or (Rarely) B). Weekly C). Daily
How often do you have headaches?

A). Never or (Rarely) B). Weekly C). Daily
Do you suffer from chemical sensitivities?
A). No C). Yes
Do you suffer from frequent infections?

A). No C). Yes
Do you often feel groggy when you wake up?
A). Never or (Rarely) B). Weekly C). Daily
How often do you find it difficult to relax?
A). Never or (Rarely) B). Weekly C). Daily
Do you suffer from excessive stress?

A). Never or (Rarely) B). Weekly C). Daily
How often do you suffer from insomnia?

A). Never or (Rarely) B). Weekly C). Daily
How often do you have mood swings?

A). Never or (Rarely) B). Weekly C). Daily
Email - Please enter your email address here. If you do not offer your email I cannot reply with an assessment. Your email does not appear when you click 'submit' Thank you!
How often do you get angry or irritable?
A). Never or (Rarely) B). Weekly C). Daily
How often do you suffer from drowsiness?

A). Never or (Rarely) B). Weekly C). Daily
Do you have poor concentration?

A). Never or (Rarely) B). Weekly C). Daily
How often do you suffer from sinus problems?

A). Never or (Rarely) B). Weekly C). Daily
Do you suffer from allergies?
A). No C). Yes
Do you drink tap water regularly?

A). Never or (Rarely) B). Weekly C). Daily
How many servings of fruit do you have a day?
A). 5 or more B).3-4 C). 1-2 D). None
How many servings of vegetables do you have a day?
A). 5 or more B).3-4 C). 1-2 D). None
At times of stress do you feel you sometimes aren’t breathing?
A). No C). Yes
Do you find that often speak negatively to yourself?

A). No C). Yes
Do you find it hard to tell yourself that you are beautiful?

A). No C). Yes
How often are you not able to exhibit control over the portion sizes you eat?

A). Never or (Rarely) B). Weekly C). Daily
How often do you get sugar cravings?
A). Never or (Rarely) B). Weekly C). Daily
Do you feel ready to make positive changes in your life?
A). No C). Yes
Scoring A=1; B=2; C=3; D=4
A ____ x 1 = _____
B ____ x 2 = _____
C ____ x 3 = _____
D ____ x 4 = _____
Total = _____

Score of 65 or more: Toxic load identified! Your current lifestyle exposes you to many toxic sources, predisposing you to toxic buildup in your system and greatly overtaxing your liver and it ability to function efficiently. It is recommended that you complete the supervised 30 day Rejuvenate Detoxification Program. This program should be repeated every three months for one year and then similarly for two following years if your detoxification questionnaire scores remains above 65.

Score of 36-65: At Risk! You are currently showing some signs and symptoms of toxic exposure. This places you at risk for toxic accumulation and you have many risk factors for further toxic exposure. It is recommended that you complete the supervised 30 day Rejuvenate Detoxification Program. This program should be repeated every five months for one year and then similarly for to following years if your detoxification questionnaire scores remains between 40-65.

Score of 28-35: Time to assess! Though relatively healthy, some symptoms are starting to surface and there are a few factors that may place you at risk. It is recommended that you complete the supervised 30 day Rejuvenate Detoxification Program. This program should be repeated once a year and then similarly for to following years if your detoxification questionnaire scores remains between 28-35.

Score 28 or less: Living clean! Congratulations…your current lifestyle does not predispose you to toxic load and you are showing virtually no symptoms of toxicity. Keep up the good work!

*Note: this questionnaire is not a replacement for primary care medical screening.
Please submit this form when you are finished scoring yourself. Enter your score and any questions you may have in the field below the scoring box. Then enter your contact information if you wish to receive further information about the Rejuvenate Detox Program.

Program includes: Detox Manual, group participation, expert nutritionist to lead the way, recipes, meal plans, enrollment in 7-day precleanse program, meditation CD, pilates/ yoga DVD, invitation into the member's only detox forum. Please note*this is a food baed detoxification program. This program is not based on fasting, overuse of supplementation or empty promises. This is a food based detoxification program that you can live by!

Score of 65 or more: Toxic load identified! Your current lifestyle exposes you to many toxic sources, predisposing you to toxic buildup in your system and greatly overtaxing your liver and it ability to function efficiently. It is recommended that you complete the supervised 30 day Rejuvenate Detoxification Program. This program should be repeated every three months for one year and then similarly for two following years if your detoxification questionnaire scores remains above 65.

Score of 36-65: At Risk! You are currently showing some signs and symptoms of toxic exposure. This places you at risk for toxic accumulation and you have many risk factors for further toxic exposure. It is recommended that you complete the supervised 30 day Rejuvenate Detoxification Program. This program should be repeated every five months for one year and then similarly for to following years if your detoxification questionnaire scores remains between 40-65.

Score of 28-35: Time to assess! Though relatively healthy, some symptoms are starting to surface and there are a few factors that may place you at risk. It is recommended that you complete the supervised 30 day Rejuvenate Detoxification Program. This program should be repeated once a year and then similarly for to following years if your detoxification questionnaire scores remains between 28-35.

Score 28 or less: Living clean! Congratulations…your current lifestyle does not predispose you to toxic load and you are showing virtually no symptoms of toxicity. Keep up the good work!

*Note: this questionnaire is not a replacement for primary care medical screening.
I would like to learn more about the Rejuvenate Group Detox Program!
Please call me when you are free! Please email me with more information Please let me know when the next group program starts!
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