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DETOX PROGRAM
	21-Day Detoxification Program 30 Days to Ultimate Fat Loss Our Team Detox Testimonials Before & After Testimonials Audio Detox Testimonials Sample Recipes FAQs Truth about sugar in food (video)

TOXICITY EVALUATION

IMPORTANT: If you are on any prescription medication or have a specific condition, you MUST complete the Evaluation for your health. One of our doctors will get back with you.

If the above does NOT pertain to you, please proceed to ORDER NOW!

YOU DO NOT HAVE TO FILL THIS OUT IF YOU ARE NOT ON MEDICATION OR HAVE A MEDICAL CONDITION.

The Toxicity Survey is designed to aid the practioner in assessing a patient or client's potential for a
Clinical Purification" program. Take this test and I will evaluate your score and let you know if you qualify for the program.

Section I: Symptoms
Rate each of the following based upon your health profile for the last 90 days.

Enter the corresponding number in the following questions.

0 = Rarely or Never experience the symptom

1 = Occasionally experience the symptom, effect is NOT severe

2 = Occasionally experience the symptom, effect IS severe

3 = Frequently experience the symptom, effect is NOT severe

4 = Frequently experience the symptom, effect IS severe

 

1. Digestive A. Nausea and/or vomiting B. Diarrhea C. Constipation D. Bloated Feeling E. Belching and/or passing gas F. Heartburn TOTAL	2. Ears A. Itchy ears B. Earaches, ear infections C. Drainage from ear D. Ringing in ears, hearing loss TOTAL	3. Emotions A. Mood Swings B. Anxiety, fear, nervousness C. Anger, irritability D. Depression E. Sense of despair F. Apathy/lethargy TOTAL
4. Energy/Activity A. Fatigue/sluggishness B. Hyperactivity C. Restlessness D. Insomnia E. Startled awake at night TOTAL	5. Eyes A. Watery, Itchy Eyes B. Swollen, reddened C. Dark circles under eyes D. Blurred/tunnel vision TOTAL	6. Head A. Headaches B. Faintness C. Dizziness D. Pressure TOTAL
7. Lungs A. Chest congestion B. Asthma, bronchitis C. Shortness of breath D. Difficulty breathing TOTAL	8. Mind A. Poor memory B. Confusion C. Poor concentration D. Poor coordination E. Difficulty making decisions F. Stuttering, stammering G. Slurred Speech H. Learning disabilities TOTAL	9. Mouth/Throat A. Chronic coughing B. Gagging, need to clear throat C. Swollen or discolored tongue, gums, lips D. Blurred/tunnel vision TOTAL
10. Nose A. Stuffy Nose B. Sinus Problems C. Hay fever D. Sneezing attacks E. Excessive mucous TOTAL	11. Skin A. Acne B. Hives, rashes, dry skin C. Hair loss D. Flushing E. Excessive sweating TOTAL	12. Heart A. Skipped heartbeats B. Rapid heartbeats C. Chest pains TOTAL
13. Joints/Muscles A. Pain or aches in joints B. Rheumatiod arthritis C. Osteoarthritis D. Stiffness, limited movement E. Pain, aches in muscles F. Recurrent back pain G. Feeling of weakness or tiredness TOTAL	14. Weight A. Binge eating/drinking B. Craving certain foods C. Excessive weight D. Compulsive eating E. Water retentio F. Underweight TOTAL	15. Other A. Frequent illness B. Frequent or urgent urination C. Leaky bladder TOTAL
		GRAND TOTAL
With your order you will receive: 1. The supplements for detoxification. 2. Doctor up to seven days per week for 21 days. 3. The literature and a CD of information and instructions of the program. All of this for only $270   CONTACT INFO * required   Name*: Phone*: Email*: PLEASE BE SURE BOTH EMAIL ADDRESSES ARE CORRECT AND MATCH. Validate Email*: How did you hear about the program?*: If you have not heard back from us within 24 hours, your email address may be incorrect. If this is the case, please revisit our site and resubmit this evaluation. - Thank you! Additional Comments and/or Health Issues: PLEASE BE AWARE:: Due to other sites copying my material, supplement protocol, and using supplements which are not the same as mine, I cannot be responsible for your safety. I strongly recommend against ordering a 21 day detox program from these sites.