Flojo’s Easy Detox Questionnaire

Please copy and paste this page into an email to me before you start Flojo’s Easy Detox.

Name:

Age:

Email:

Current medications:

What are the main symptoms or areas of health that you are hoping to alleviate in this four week course? :

Is there anything you think I should be aware of before we start such as pre-existing medical conditions, allergies, addictions, eating disorders, pregnancy, and/or major executive function issues etc?:

Please score how you currently (i.e. this week) feel in the following areas. Please note that the scale is different for each area! Choose just a single number score for each area but feel free to add any extra information below:

Energy

No Energy   =   0 – 15   =   High Energy

Your energy score:

Details:

Sleep

Poor Sleep   =  0 – 10   =  Deep, refreshing sleep

Your sleep score:

Details:

Mood

Mostly angry or sad = 0 – 15 = Mostly happy and connected

Your mood score:

Details:

Skin

Dull, dry or spotty; eczema or psoriasis = 0 – 10 = Clear, supple skin

Your skin score:

Details:

Headaches

Frequent, severe, lasting or migraines  = 0 – 10 = None or very rare headaches

Your headache score:

Details:

Digestion

Heartburn, constipation, diarrhoea, cramps = 0 – 15 = Smooth, efficient

Your digestion score:

Details:

Stress

Unable to cope with external stress = 0 – 10 = Easily deal with stressful situations

Your stress score:

Details:

Sinuses

Frequent pain or dripping nose = 0 – 5 = No sinus issues

Your sinus score:

Details:

Physical pain

High and/or constant level = 0 – 10 = no current pain other than a recent accident

Your pain score:

Details:

Add your individual scores up to get your total score _____/100

Are there any foods that you find difficult or impossible to eat due to allergy / intolerance / moral / sensory reasons? Please give details:

Are there any foods that you feel you have an addiction to or that make you anxious about possibly giving up? Please give details:

To your knowledge do you have any particular sensitivities or allergies such as to certain foodstuffs, to mould or to certain chemicals? :

Anything else you think I should know? :