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| First Name: |
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Section A : liver congestion, biliary stress, bowel stress
Do
You...
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Bad breath, halitosis |
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Loss of taste |
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Burning or nervous stomach, eating relieves |
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Gas shortly after eating |
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Indigestion 1/2 to 1 hour after eating, may last 3-4 hours |
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Difficulty digesting fruits or vegetables, undigested foods found in stools |
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Acid or spicy foods upset stomach |
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Nausea or vomiting |
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Diarrhea |
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Constipation |
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Bloated feeling |
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Belching or passing gas |
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Heartburn |
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Moderate to severe pain under right side of rib cage |
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Abdominal pain worse with deep breathing |
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Bitter fluid repeats after eating |
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Bloated, full feeling |
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Belching, heartburn, gas |
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Fatty foods cause indigestion |
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Nausea and/or vomiting |
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Unexplained itchy skin worse at night |
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General feeling of poor health |
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Fatigue, weakness, exhaustion |
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Unable to concentrate, irritable, confused |
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Aching muscles |
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Trembling hands |
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Weight gain due to water retention |
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Swollen feet and/or legs |
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Bleeding tendencies in gums, nose |
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Loss of chest and armpit hair |
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Reddened skin, especially palms |
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Dark urine, diminished flow |
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Dry flaky skin and/or hair |
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Loss of appetite and weight |
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Easy bruising |
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Thinning of pubic hair |
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Feeling of extreme dryness |
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Loss of skin elasticity |
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Recent tests show abnormal liver enzymes or gallbladder function |
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Lower bowel gas and or bloating several hours after eating |
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Feet burn |
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Whites of eyes (sclera) yellow |
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Dry skin itchy feet and/or skin peels on feet |
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Brown spots or bronzing of skin |
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Bitter metallic taste in mouth |
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Blurred vision |
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Headache over eyes |
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Feel nauseous, queasy or gag easily |
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Yellowing cast to skin/ eyes |
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Color of stools light brown or yellow |
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Color of stools are clay colored |
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Greasy or high fat foods cause distress |
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Pain between shoulder blades |
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Dark circles under eyes |
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"acid" breath |
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history of gallbladder attacks or gallstones |
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gallbladder removed (YES) |
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appetite reduced |
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Watery or itchy eyes |
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Swollen, reddened or sticky eyelids |
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Bags or dark circles under eyes |
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Blurred or tunnel vision (excluding near or far-sightedness) |
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Headaches |
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Faintness |
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Dizziness |
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Insomnia |
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Itchy ears |
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Earaches, ear infections |
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Drainage from ear |
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Ringing in ears, hearing loss |
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Stuffy nose |
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Sinus problems |
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Hay fever |
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Sneezing attacks |
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Excessive mucus formation |
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Chronic coughing |
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Gagging, frequent need to clear throat |
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Sore throat, hoarseness, loss of voice |
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Swollen or discolored tongue, gums, lips |
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Cancer sores |
Section B: Colon Detoxification
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Coated tongue or "fuzzy" debris on tongue |
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Pass large amounts of foul smelling gas |
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Irritable bowel or mucous colitis |
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Constipation, diarrhea alternating or stools alternate from soft to watery |
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Bowel movements painful or difficult, constipation and/or laxatives used |
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Burning or itching anus |
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Pain or aches in joints |
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Arthritis |
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Stiffness or limitation of movement |
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Pain or aches in muscles |
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Feeling of weakness or tiredness |
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Acne |
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Hives rashes or dry skin |
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Hair loss |
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Flushing or hot flashes |
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Excessive sweating |