angelluis - Home

Do you typically drink non-filtered water? *

Yes

No

Do you typically eat fresh foods; fruits and vegetables, etc...that are NOT organic? *

Yes

No

Do you typically eat animal products: chicken, beef, eggs, etc...that are NOT grass feed or hormone free? *

Yes

No

Do you eat large fish (swordfish, tuna, shark, tilefish) or sushi regularly (once a week)? *

Yes

No

Do you suffer from headaches or have difficulty concentrating? *

Yes

No

Do you suffer from allergies, frequent congestion or sinus problems? *

Yes

No

Do you experience indigestion, acid reflux, intestinal bloating or gas after meals? *

Yes

No

Do you suffer from constipation or have less then one bowel movement per day? *

Yes

No

Are you “over weight” or dieting and STILL having difficultly “losing weight”? *

Yes

No

Do you have mercury amalgam fillings? *

Yes

No

Do you dry clean your clothes? *

Yes

No

Do you use/store hazardous household cleaning product or garden chemicals in your home/apt? *

Yes

No

Do you have your home treated by an exterminator regularly? *

Yes

No

Are you bothered by one or more of the following: gasoline or diesel fumes, perfumes, new car smells, fabric stores, dry cleaning, hair spray or other strong odors including tobacco smoke or chlorinated water. *

Yes

No

Do you have a negative reaction when you consume foods containing MSG, sulfites (wine, salad bars, dried fruit), sodium benzoate (preservative), red wine, coffee, cheese, bananas or chocolate, small amounts of alcohol or eating food with garlic and onions? *

Yes

No

Do you regularly consume any of the following substances or medications:
• Acetaminophen (Tylenol)
• Acid blocking drugs; Tagamet Zantac, Pepcid, Prilosec, Prevacid
• Hormone medications in pills/patches or creams; the pill, estrogen, progesterone, etc...
• Ibuprofen or Naproxen *

Yes

No

Additional Information (Optional)

If you have answered "yes" to 4 or more questions, you may be experiencing toxic overload and should consider a detoxification program.

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Name

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