Detox Funnel Assessment

Please note that this assessment does not provide any medical diagnosis and does not create a doctor-patient relationship between you and Dr. Diane Fong, ND or any medical professional at NaturalStart Naturopathic Family Medicine, Inc. dba Cleanbody. This assessment is designed as an educational tool to help you uncover the factors that may be causing your detox funnel to get clogged. Based on your answers, this tool will educate you about possible ways to address these factors with diet and lifestyle modifications, environmental toxin clean up, emotional release therapy, detoxification, and regenerative modalities.

Name

Gender Male Female

Birth Date

Please list your five major health concerns in order of importance:

Notes

Detox Funnel

	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Pain between shoulder blades
Stomach upset by greasy foods
Greasy or shiny stools
Nausea
Sea, car, airplane or motion sickness
History of morning sickness	No	Yes
Light or clay colored stools
Dry skin, itchy feet or skin peels on feet
Headache over eyes
Gallbladder attacks	Never	Years ago	Within last year	Within past 3 months
Gallbladder removed	No	Yes
History of hepatitis	No	Yes
Long term use of prescription/recreational drugs	No	Yes
Sensitive to chemicals (perfume, cleaning agents, etc.)
Sensitive to tobacco smoke
Exposure to diesel fumes
Pain under right side of rib cage
Hemorrhoids or varicose veins
Nutrasweet (aspartame) consumption
Sensitive to Nutrasweet (aspartame)
Chronic fatigue or Fibromyalgia
Bitter taste in mouth, especially after meals
Become sick if you were to drink wine	No	Yes
Easily intoxicated if you were to drink wine	No	Yes
Easily hung over if you were to drink wine	No	Yes
Alcohol per week	<3	<7	<14	>14
Recovering alcoholic	No	Yes

Food & Toxins

Food

Food	Do not Consume at all	Consume or use 1-2 times monthly	Consume or use weekly	Consume or use daily
Non-Organic Foods
Gluten
Dairy
Alcohol
Cigarettes
Recreational Drugs
Caffeine
GMO Foods (Soy, Corn, etc.)
Packaged Foods
Luncheon Meats
Fast Food
Red Meat (Beef, Pork, Lamb, Veal, etc.)
Excess fat, especially trans fats
Sugar and all its relatives
Artificial sweeteners
Refined carbohydrates, including white rice
Fish High in Mercury (Tuna, etc.)
Canned Food

Toxin

Toxic exposures	Do not Consume at all	Consume or use 1-2 times monthly	Consume or use weekly	Consume or use daily
Do you use non-stick cookware?
Do you use plastic containers?
Do you filter your tap water?
Do you use air fresheners?
Do you use perfume?
Do you use deodorant with aluminum?
Are there fragrances in your personal care products?
Do you use non-organic, chemical-based products?
Do you use a vinyl shower curtain?
Do you use green cleaning supplies?
Was your home built before 1978?
Do you have foam furniture?
Do you use compact fluorescent light bulbs (CFLS)?
Do you use pesticides or insecticides?
Do you have a wood deck, playground or picnic table made before 2005?
Do you wear a bluetooth device (apple watch, fit bit)?
Do you have root canals?
Do you have amalgam fillings?
Do you see mold in your home or office?
Do you take medications?

Stress & Harmones

Stress

Rate Your Stress Level in the Following Areas	None	Low	Moderate	High
kids
parents
home
work
Friends
Money
Health
Love Life
Body Image
Self Confidence

Adrenals

Adrenals	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Tend to be a "night person"
Difficulty falling asleep
Slow starter in the morning
Tend to be keyed up, trouble calming down
Blood pressure above 120/80
Headache after exercising
Feeling wired or jittery after drinking coffee
Clench or grind teeth
Calm on the outside, troubled on the inside
Chronic low back pain, worse with fatigue
Become dizzy when standing up suddenly
Difficulty maintaining manipulative correction
Pain after manipulative correction
Arthritic tendencies
Crave salty foods
Salt foods before tasting
Perspire easily
Chronic fatigue, or get drowsy often
Afternoon yawning
Afternoon headache
Asthma, wheezing or difficulty breathing
Pain on the medial or inner side of the knee
Tendency to sprain ankles or "shin splints"
Tendency to need sunglasses
Allergies and/or hives
Weakness, dizziness

Thyroid

Thyroid	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Sensitive/allergic to iodine
Difficulty gaining weight, even with large appetite
Fast pulse at rest
Intolerance to high temperatures
Difficulty losing weight
Mentally sluggish, reduced initiative
Easily fatigued, sleepy during the day
Sensitive to cold, poor circulation (cold hands and feet)
Constipation, chronic
Excessive hair loss and/or coarse hair
Morning headaches, wear off during the day
Loss of lateral 1/3 of eyebrow

Male Hormones

	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Decreased sexual function
Have "man boobs"
Difficulty losing weight
Low sex drive
Fatigue
Reduced lean muscle mass
Irritability
Erectile dysfunction
Depression

Female Hormones

	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Depression during periods
Mood swings associated with periods (PMS)
Crave chocolate around periods
Breast tenderness associated with cycle
Excessive menstrual flow
Scanty blood flow during periods
Occasional skipped periods
Variations in menstrual cycles
Endometriosis
Uterine fibroids
Breast fibroids, benign masses
Painful intercourse (dysparenia)
Vaginal discharge
Vaginal dryness
Vaginal itchiness
Gain weight around hips, thighs and buttocks
Excess facial or body hair
Hot flashes
Night sweats (in menopausal females)

Genes

Do you or members in your family have the following conditions?	0 Family Members (Including self)	1-2 Family Members (Including self)	3-4 family members (including self)	5 family members or more (including self)
Autoimmune conditions: e.g. multiple sclerosis, rheumatoid arthritis, autoimmune thyroid
Mood and mental health issues: mood swings, depression, anxiety, bipolar, OCD etc.
Infertility (both male and female), history of miscarriage or pregnancy related complications e.g. pre-eclampsia
Cardiovascular disease: high blood pressure, poor circulation, heart attack, stroke
Hormonal imbalances: PCOS, PMS, fibroids, endometriosis
Memory & sleep problems: insomnia, dementia, Alzheimer's disease
Chronic Fatigue Syndrome or Myalgic Encephalomyelitis (ME)
Allergies and histamine intolerance: eczema, hay fever, headaches, congestion, hives etc.
Poor bile production leading to digestive problems, fat malabsorption, acid reflux, and gallbladder issues like gall stones, gallbladder surgery
Inflammatory condition: arthritis, inflammatory bowel disease (IBD), fibromyalgia
Cancer: all types

Exits

Upper GI

Upper GI	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)
Belching or gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
Vegan diet (no dairy, meat, fish or eggs)	No	Yes
Bad breath (halitosis)
Loss of taste for meat
Sweat has a strong odor
Stomach upset by taking vitamins
Sense of excess fullness after meals
Feel like skipping breakfast
Feel better if you don’t eat
Sleepy after meals
Fingernails chip, peel or break easily
Anemia unresponsive to iron
Stomach pains or cramps
Diarrhea, chronic
Diarrhea shortly after meals
Black or tarry colored stools
Undigested food in stool

Small Intestine

Small Intestine	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Food allergies
Heartburn or acid reflux
Specific foods make you tired or bloated	No	Yes
Pulse speeds after eating
Airborne allergies
Experience hives
Sinus congestion, "stuffy head"
Crave bread or noodles
Alternating constipation and diarrhea
Crohn's disease	No	Yes in the past	Currently mild condition	Severe
Wheat or grain sensitivity
Dairy sensitivity
Are there foods you could not give up	No	Yes
Asthma, sinus infections, stuffy nose
Bizarre vivid dreams, nightmares
Use over-the-counter pain medications
Feel spacey or unreal

Large Intestine

Large Intestine	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Anus itches
Coated tongue
Feel worse in moldy or musty place
Taken antibiotic for a total accumulated time of	Never	< 1 month	< 3 months	> 3 months
Fungus or yeast infections
Ring worm, "jock itch", "athletes foot", nail fungus
Yeast symptoms increase with sugar, starch or alcohol
Stools hard or difficult to pass
History of parasites	No	Yes
Less than one bowel movement per day
Stools have corners or edges, are flat or ribbon shaped
Stools are not well formed (loose)
Irritable bowel or mucus colitis
Blood in stool
Mucus in stool
Excessive foul smelling lower bowel gas
Bad breath or strong body odors
Painful to press along outer sides of thighs (Iliotibial Band)
Cramping in lower abdominal region
Dark circles under eyes

Kidney/Bladder

Kidney/Bladder	No symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)
Pain in mid-back region
Puffy around the eyes, dark circles under eyes
History of kidney stones	No	Yes
Cloudy, bloody or darkened urine
Urine has a strong odor
Increased urinary frequency
Bedwetting
Pain on urination
Diagnosed with interstitial cystitis

Lymphatic System

Lymphatic System	No, symptom does not occur	Yes, minor or mild symptom, rarely occurs (monthly)	Moderate symptom, occurs occasionally (weekly)	Severe symptom, occurs frequently (daily)
Swelling in your fingers (rings fitting more tightly?)
Feeling stiff and sore when you wake up in the morning
Cold hands and feet
Brain fog
Chronic fatigue
Depression
Bloating
Excess weight
Food sensitivities
Digestive issues
Dry or itchy skin
Sinus infections
Increased colds and flu
Weakened immunity
Enlarged lymph nodes
Allergies
Unexplained injury and illness
Constipation
Parasites