Ready to take your Detox Program assessment?

February 27, 2020

When answering questions, simply rate each of the following symptoms from zero to four.

 Please be totally honest, this is your health! Enter one of the following numbers next to each symptom.

0 – Never or almost never have the symptom

1 – Occasionally has it, effect is not severe

2 – Occasionally has it, effect is severe

3 – Frequently has it, effect is not severe

4 – Frequently has it, effect is severe

Email:
Name
Phone Number
Are you a New or Existing patient at TPA Wellness Center
[ Digestive ]
Heartburn...
Symptom Questionnaire for Detox Candidates 1
[ Digestive ]
Belching, Passing gas...
Symptom Questionnaire for Detox Candidates 1
[ Digestive ]
Constipation...
Symptom Questionnaire for Detox Candidates 1
[ Digestive ]
Bloated feeling...
Symptom Questionnaire for Detox Candidates 1
[ Digestive ]
Diarrhea...
Symptom Questionnaire for Detox Candidates 1
[ Digestive ]
Nausea or Vomiting...
Symptom Questionnaire for Detox Candidates 1
[ Energy/Activity ]
Fatigue, sluggishness...
Symptom Questionnaire for Detox Candidates 1
[ Energy/Activity ]
Apathy...
Symptom Questionnaire for Detox Candidates 1
[ Energy/Activity ]
Restlessness...
Symptom Questionnaire for Detox Candidates 1
[ Energy/Activity ]
Hyperactivity...
Symptom Questionnaire for Detox Candidates 1
[ Joints/Muscles ]
Pain or aches in joints...
Symptom Questionnaire for Detox Candidates 1
[ Joints/Muscles ]
Arthritis...
Symptom Questionnaire for Detox Candidates 1
[ Joints/Muscles ]
Stiff, limited movement...
Symptom Questionnaire for Detox Candidates 1
[ Joints/Muscles ]
Pain, aches, or cramping in muscles...
Symptom Questionnaire for Detox Candidates 1
[ Joints/Muscles ]
Weakness or tiredness...
Symptom Questionnaire for Detox Candidates 1
1 out of 5
[ Eyes ]
Blurred, Tunnel Vision...
Symptom Questionnaire for Detox Candidates 1
[ Eyes ]
Watery, Itchy eyes...
Symptom Questionnaire for Detox Candidates 1
[ Eyes ]
Swollen, Reddened, Sticky Eyelids...
Symptom Questionnaire for Detox Candidates 1
[ Nose ]
Stuffy nose...
Symptom Questionnaire for Detox Candidates 1
[ Nose ]
Hay fever, allergies...
Symptom Questionnaire for Detox Candidates 1
[ Nose ]
Excessive mucus...
Symptom Questionnaire for Detox Candidates 1
[ Nose ]
Sneezing attacks...
Symptom Questionnaire for Detox Candidates 1
[ Nose ]
Sinus problems...
Symptom Questionnaire for Detox Candidates 1
[ Ears ]
Drainage from ears...
Symptom Questionnaire for Detox Candidates 1
[ Ears ]
Itchy ears...
Symptom Questionnaire for Detox Candidates 1
[ Ears ]
Earaches, ear infections...
Symptom Questionnaire for Detox Candidates 1
[ Ears ]
Ringing in ears, hearing loss...
Symptom Questionnaire for Detox Candidates 1
2 out of 5
[ Lungs ]
Chest Congestion...
Symptom Questionnaire for Detox Candidates 1
[ Lungs ]
Asthma, Bronchitis...
Symptom Questionnaire for Detox Candidates 1
[ Lungs ]
Shortness of breath...
Symptom Questionnaire for Detox Candidates 1
[ Lungs ]
Difficulty breathing...
Symptom Questionnaire for Detox Candidates 1
[ Head ]
Headaches...
Symptom Questionnaire for Detox Candidates 1
[ Head ]
Dizziness...
Symptom Questionnaire for Detox Candidates 1
[ Head ]
Faintness...
Symptom Questionnaire for Detox Candidates 1
[ Head ]
Insomnia...
Symptom Questionnaire for Detox Candidates 1
[ Heart ]
Chest pain...
Symptom Questionnaire for Detox Candidates 1
[ Heart ]
Rapid heartbeats...
Symptom Questionnaire for Detox Candidates 1
[ Heart ]
Skipped heartbeats...
Symptom Questionnaire for Detox Candidates 1
3 out of 5
[ Weight ]
Binge eating/drinking...
Symptom Questionnaire for Detox Candidates 1
[ Weight ]
Craving certain foods...
Symptom Questionnaire for Detox Candidates 1
[ Weight ]
Excessive weight gain...
Symptom Questionnaire for Detox Candidates 1
[ Weight ]
Compulsive eating...
Symptom Questionnaire for Detox Candidates 1
[ Weight ]
Water retention...
Symptom Questionnaire for Detox Candidates 1
[ Weight ]
Underweight...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Poor Memory...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Confusion...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Poor Concentration...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Poor Coordination...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Difficulty making decisions...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Stuttering, stammering...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Slurred speech...
Symptom Questionnaire for Detox Candidates 1
[ Mind ]
Learning Disabilities...
Symptom Questionnaire for Detox Candidates 1
[ Emotions ]
Mood Swings...
Symptom Questionnaire for Detox Candidates 1
[ Emotions ]
Anxiety, Fear, Nervousness...
Symptom Questionnaire for Detox Candidates 1
[ Emotions ]
Anger, Irritability...
Symptom Questionnaire for Detox Candidates 1
[ Emotions ]
Depression...
Symptom Questionnaire for Detox Candidates 1
4 out of 5
[ Mouth/Throat ]
Chronic coughing...
Symptom Questionnaire for Detox Candidates 1
[ Mouth/Throat ]
Gagging, need to clear throat...
Symptom Questionnaire for Detox Candidates 1
[ Mouth/Throat ]
Sore throat, hoarse...
Symptom Questionnaire for Detox Candidates 1
[ Mouth/Throat ]
Swollen or discolored gums or lips...
Symptom Questionnaire for Detox Candidates 1
[ Mouth/Throat ]
Canker sores...
Symptom Questionnaire for Detox Candidates 1
[ Skin ]
Acne...
Symptom Questionnaire for Detox Candidates 1
[ Skin ]
Excessive sweating...
Symptom Questionnaire for Detox Candidates 1
[ Skin ]
Hives, rashes, dry skin...
Symptom Questionnaire for Detox Candidates 1
[ Skin ]
Hair loss...
Symptom Questionnaire for Detox Candidates 1
[ Skin ]
Flushing, hot flashes...
Symptom Questionnaire for Detox Candidates 1
[ Other ]
Frequent illness...
Symptom Questionnaire for Detox Candidates 1
[ Other ]
Frequent, urgent urination...
Symptom Questionnaire for Detox Candidates 1
[ Other ]
Genital itch, discharge...
Symptom Questionnaire for Detox Candidates 1
5 out of 5

Submit your answers to see the results of Symptoms Assessment for Detox - February 27, 2020