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The Detoxification Questionnaire (from www.heelusa.com)

The Detoxification Questionnaire is a self-administered test that includes questions about all the major toxicity symptoms. Patients evaluate their symptoms on a scale of 0 to 4.

Score the questions below using the following key:

0 = never or almost never have the symptom
1 = occassionally have it
2 = occassionally have it, effect is severe
3 = frequently have it, effect not severe
4 = frequently have it, effect is severe

By using this form online it will automatically calculate the score for your use.


EmotionsScore
Irritability 0 1 2 3 4
Nervousness 0 1 2 3 4
Mood swings 0 1 2 3 4
Frequent crying 0 1 2 3 4
Aggressive behavior, ie... road rage 0 1 2 3 4
Anxiety 0 1 2 3 4
Fear 0 1 2 3 4
Confusion 0 1 2 3 4
* Depression 0 1 2 3 4
* Suicidal thoughts 0 1 2 3 4
Total Emotions:

SkinScore
Increased sweating, ear wax, oily skin 0 1 2 3 4
Skin rashes 0 1 2 3 4
Brown spots on hands and face 0 1 2 3 4
Boils 0 1 2 3 4
Skin tags (small hanging warts) 0 1 2 3 4
Acne 0 1 2 3 4
Eczema 0 1 2 3 4
Fever blisters 0 1 2 3 4
Warts 0 1 2 3 4
Total Skin:

Ear, Nose and ThroatScore
Increased salivation 0 1 2 3 4
Mouth ulcers 0 1 2 3 4
Common cold 0 1 2 3 4
Sinusitis 0 1 2 3 4
Sore throats 0 1 2 3 4
* Ear infections 0 1 2 3 4
Hay fever 0 1 2 3 4
Loss of smell 0 1 2 3 4
Cough 0 1 2 3 4
Total Ear, Nose and Throat:

Mind and BrainScore
Hyperactivity 0 1 2 3 4
Stammering when speaking or problem finding words 0 1 2 3 4
Difficulty in concentration 0 1 2 3 4
Sleep disturbance 0 1 2 3 4
Difficulty in making decisions 0 1 2 3 4
  Headache 0 1 2 3 4
Poor memory 0 1 2 3 4
Poor coordination 0 1 2 3 4
* Compulsive behavior 0 1 2 3 4
* Sleep disturbance 0 1 2 3 4
Memory loss 0 1 2 3 4
Total Mind and Brain:

Digestive SystemScore
Loose stools 0 1 2 3 4
Diarrhea 0 1 2 3 4
Heartburn 0 1 2 3 4
Constipation 0 1 2 3 4
Bloating 0 1 2 3 4
Abdominal pain 0 1 2 3 4
Intolerance to certain foods 0 1 2 3 4
Nausea or vomiting 0 1 2 3 4
* Severe diarrhea with blood or mucous 0 1 2 3 4
Total Digestive System:

KidneyScore
Increase in urination frequency and amount 0 1 2 3 4
Needing to get up in the night to pass urine 0 1 2 3 4
* Urinary tract infections and cystitis 0 1 2 3 4
* Kidney stones 0 1 2 3 4
* Blood in the urine 0 1 2 3 4
Total Kidney:

Joints and MusclesScore
Fleeting muscle aches or joint aches 0 1 2 3 4
Tendinitis (e.g., tennis elbow, golfer's elbow, achilles
tendinitis) 0 1 2 3 4
Gout 0 1 2 3 4
Arthritis 0 1 2 3 4
Fibromyalgia 0 1 2 3 4
Total Joints and Muscles:

MetabolismScore
Feeling of coldness 0 1 2 3 4
Hypoglycemia 0 1 2 3 4
Craving certain foods 0 1 2 3 4
Water retention 0 1 2 3 4
Obesity 0 1 2 3 4
Cellulite 0 1 2 3 4
Total Metabolism:

* These symptoms are indications of conditions that should not be treated with Heel Detoxification and Drainage protocols alone.


Grand Total:

Detoxification Point Scale
Total Points: Less Than 100

Patient with mild to moderate toxicity
Total Points:Greater than 100

Patient with moderate to severe toxicity.

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