toxicity profile questionnaire
This assessment is to be completed prior to the initial meeting of the program. The goal of this assessment is to identify those areas in your life and diet that need attention so that you are not building a toxic load, and you can improve your health by reducing your toxic load, and you can improve your health by reducing your toxic burden. Please circle the appropriate response, "Y" for yeas and "N" for no. More than five "yes" answers means that you have an increased risk of a toxic burden. You do not have an increased risk of toxic burden if you answered "yes" for 9, 11, and 13.
1. Do you eat fast-food meals at least three times a week?
2. Are you overweight?3. Do you tend to overeat?
4. Do you consume "sugar free" food sweetened with aspartame or use Equal?
5. Do you regularly or knowingly consume foods that contain MSG (may be in soy protein
isolate, soy sauce, hydrolyzed vegetable protein)?
6. Do you eat foods, especially packaged foods, that contain artificial colors?
7. Do you eat refined carbs at any time during the day?
8. Do you eat non-organic produce?
9. Do you eat at least 7-9 servings of fresh fruits and vegetables per day (1/2 cup servings)?
10. Do you drink sodas every day or several times a week?
11. Do you drink organic coffee if you are a coffee drinker?
12. Do you drink more than two cups of coffee per day?
13. Do you drink at least 8 glasses or 2 quarts of water per day?
14. Do you cook or reheat foods in plastic containers?
15. Do you microwave your foods?
16. Are you presently using prescription drugs?
17. Have you ever experienced an allergic reaction to caffeine or caffeine-containing products?
18. Do you currently smoke or use tobacco products?
19. Have you experienced an allergic reaction to or have had side effects from any medication?
20. Have you smoked within the past ten years?
21. Have you ever used recreational drugs?
22. Do you experience brain fog or drowsiness?
23. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?
24. Do you feel ill after consuming even small amounts of alcohol?
25. Have you ever been exposed to mold in your house or work environment?
26. Have you ever been exposed to harmful chemicals (petrochemicals, organic solvents, etc.)?
This could be one great exposure or several small exposures.
27. Have you ever had a chemical dependence?
28. Have you ever had asthma?
29. Have you ever had chronic fatigue or fibromyalgia?
30. Do you have allergies to environmental substances or food?
31. Do you work in an environment in which you are directly or indirectly exposed to toxins (heavy metals, industrial chemicals, etc.)?
Total Yes Answers: ___________
1. Do you eat fast-food meals at least three times a week?
2. Are you overweight?3. Do you tend to overeat?
4. Do you consume "sugar free" food sweetened with aspartame or use Equal?
5. Do you regularly or knowingly consume foods that contain MSG (may be in soy protein
isolate, soy sauce, hydrolyzed vegetable protein)?
6. Do you eat foods, especially packaged foods, that contain artificial colors?
7. Do you eat refined carbs at any time during the day?
8. Do you eat non-organic produce?
9. Do you eat at least 7-9 servings of fresh fruits and vegetables per day (1/2 cup servings)?
10. Do you drink sodas every day or several times a week?
11. Do you drink organic coffee if you are a coffee drinker?
12. Do you drink more than two cups of coffee per day?
13. Do you drink at least 8 glasses or 2 quarts of water per day?
14. Do you cook or reheat foods in plastic containers?
15. Do you microwave your foods?
16. Are you presently using prescription drugs?
17. Have you ever experienced an allergic reaction to caffeine or caffeine-containing products?
18. Do you currently smoke or use tobacco products?
19. Have you experienced an allergic reaction to or have had side effects from any medication?
20. Have you smoked within the past ten years?
21. Have you ever used recreational drugs?
22. Do you experience brain fog or drowsiness?
23. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?
24. Do you feel ill after consuming even small amounts of alcohol?
25. Have you ever been exposed to mold in your house or work environment?
26. Have you ever been exposed to harmful chemicals (petrochemicals, organic solvents, etc.)?
This could be one great exposure or several small exposures.
27. Have you ever had a chemical dependence?
28. Have you ever had asthma?
29. Have you ever had chronic fatigue or fibromyalgia?
30. Do you have allergies to environmental substances or food?
31. Do you work in an environment in which you are directly or indirectly exposed to toxins (heavy metals, industrial chemicals, etc.)?
Total Yes Answers: ___________
A four-week Detoxification & Educational Program, Registration price: $175
Improve your overall health, well-being and the function of your vital organs by decreasing toxins and unnecessary additives. Kate's intention is to educate you about what your body needs, what's in your food, and how to find balance without the complexity of unsustainable fad diets, media driven trends, government determined standards, and scientific inconsistencies. This unique program integrates the best detoxification methods in easy-to-follow strategies to promote extraction of deeply embedded toxins and dramatically lower the inflammatory load of the body. Kate's approach combines: -whole foods from a detox perspective -detoxifying lifestyle practices -nutritionally supportive and cleansing approaches to help you rise to new levels wellbeing! More information here... |
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Katherine M. Coleman : RYT & CNT / biophilia, LLC : yoga & holisitc nutrition therapy
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