Self Toxicity Test
Name______________ Date___________
Toxicity Self Test
Point Scale: Rate each symptom based on your health over the last 30 days.
0 = Never had a symptom
1 = Occasionally; symptom is not severe
2 = Occasionally; symptom is severe
3 = Frequently; symptom is not severe
4 = Frequently; symptom is severe
Digestion: ___Nausea or Vomiting Ears: ___Itchy ears
___Diarrhea ___ Earaches, infections
___Constipation ___Drainage
___Bloated, Hiatal problems ___Ringing
____Belching, Gas ___Balance Problems
___Gallbladder Problems Vertigo
____Heart Burn ___Loss of hearing
____Total ___Total
Emotions: ___Mood swings Eyes: ___Watery, itchy
___ Anxiety, fear, nervousness ____Swollen, red, sticky
____Anger, irritability _____Dark circles
____Depression _____Blurred, or tunnel vision
____Total ___Total
Head: ___Headaches Lungs: ___Congestion
___Faintness ___Asthma, Bronchitis
___Dizziness ___Shortness of breath
___Insomnia ___Difficult breathing
___Total ___Total
Energy:___Fatigue Mind:___Poor Memory
___Apathy, Lethargic ___Confusion
___HYPER activity ___Poor Concentration
___Restlessness ___Poor Coordination
___HYPO activity ___Difficulty making decisions
___Total
___Stuttering
___Slurred speech
___Learning disabilities, ADD etc.
___Total
Heart: ___Skipped Beats Mouth/Throat:___Chronic Coughing
___Rapid Heartbeat ___Gagging, constantly
___Chest Pain clearing throat
___Blood pressure high or low ___Sore, hoarse throat
___High Cholesterol ___Swollen, discolored
___Total tongue, gums,lips
___Canker sores
Joints/Muscles : ___Total
___Pain in Joint
___Arthritis Nose: ___Stuffy
___Weakness/Tired ___Sinus problems
___Stiffness, Limited movement ___Hay fever
___Pain in muscles ___Sneezing attacks
___Total ___Chronic/Excessive Mucus
___Total
Weight: ___Binge eating/drinking
___Crave Certain Foods Skin: ___Acne
___More than 20% overweight ___Bruise easily
for height ___Dryness
___Compulsive eating ___Hives or rash
___Water retention ___Itching
___Underweight ___Varicose veins
___Total ___Total
Other: ___Frequently sick Notes:
___Frequent, Urgent or difficult urination
___Genital itching or discharge
___Kidney stones
___Prostate Problems (MEN)
___Menstrual Problems (WOMEN)
Menopausal, irregular periods
___ Total
Score each section and record below: If any section total is greater than 10 and if the grand total is greater than 50; you may benefit from a detoxification program !!
Digestive___, Ears___, Emotions___, Energy___, Eyes___, Head___, Lungs___,
Mind___, Mouth___, Nose___, Skin___, Heart___, Joints___, Weight___, Other___,
Grand Total_____________