Detox Diet Questionnaire
QUESTIONNAIRE- CHECK YOUR DETOX POTENTIAL BY PATRICK HOLFORD
Complete this questionnaire to discover from whether you need to improve your
detoxification potential:
ALICE DETOX LODGE
If you have 4 of these symptoms you need to detox.
1- Do you often suffer from headaches or migraine?
2- Do you sometimes have ear infection / drainage and / or ringing in the ears?
3- Do you often suffer from excessive mucus, a blocked nose or sinus problems?
4- Do you suffer from acne or any other skin problems?
5- Do you sweat a lot and / or have a strong body odour?
6- Do you have a sluggish metabolism and find it hard to lose weight.
7- Or are you underweight and find it hard to gain weight?
9- Do you suffer from frequent or urgent urination?
10-Do you suffer from nausea or vomiting?
11- Do you sometimes have joints or muscle aches or pains?
12- Do you have a strong reaction to alcohol?
13- Do you suffer from bloating / water retention?
14- Does coffee leave you feel jittery or unwell?
Diet-wise the five habits to break are:
1- wheat
2- milk
3- caffeine
4- alcohol
5- bad (unsaturated) fats
Kindly fill out the following information e-mail it back to us.
Personal Details: Private and confidential for the Doctor assessment.
Download Doctor assessment here
Detox Questionnaire:
Name Date:
Work telephone number:
Home telephone number:
Cell number:
Email address:
Address (to send you the protocol):
Age:
Occupation:
How did you hear about us?
Your Medical History:
Have you had any operations?
If yes, which ones and when? Do you take any medication?
Do you take any supplements?
Do you have any allergies, if yes, to what?
History of heart problems, chest pains or stroke?
High blood pressure?
History of breathing or lung problems?
Muscle, joint or back disorder?
Have you had any major injuries or car accidents?
Diabetes or a thyroid condition?
High blood cholesterol?
Any chronic illness or condition?
Depression or anxiety?
Are you pregnant?
How much sugar do you consume per day?
How many hours of sleep on average per night?
What do you weigh?
What is your height?
Do you smoke? If yes, how many per day?
Do you drink alcohol on a daily basis? If yes, how many tots of alcohol per day?
Do you take recreational drugs? If yes, which ones and how often?
How many glasses of water do you drink per day?
How much tea and coffee do you drink per day?
How many times per week do you exercise?
What type of exercise do you do?
How much sugar do you consume per day?
How many hours of sleep do you get per night?
Do you have a pace-maker?
Are you regular with bowels movement?
Have you asked your practitioner about detoxifying?
Do you have special requests during your stay at ADL?
Could you stay without food for your 5 days stay?
(The cleansing drinks will make you feel full!)
Do you require the Doctor check up?
Kindly fill out the following information and e- mail it back to us.
Thank you, this form will be sent to our Homeopath, who in turn will inform us.
Download Doctor assessment here
www.detoxlodge.co.za