Cleanbody Assessment

Diane-68 (1)

 

Is your Detox Funnel Full? Find out with this assessment!

The Cleanbody Assessment is an in-depth assessment of your Detox funnel organs based on your symptoms and exposures. You will receive a Cleanbody Funnel score and understand the factors affecting your funnel, including food and toxin exposures, stress, genetics, and more.

The assessment takes about 10 minutes to complete. Please note, if you are completing this assessment on your mobile device, it may be more user-friendly to complete this assessment by turning your phone horizontally in the “landscape” position. 

CLEAN Your Body. Get to the ROOT CAUSE. Let’s get started!

Male Female Yes No

Alarm Systems

No, symptom does not occur Yes, minor or mild symptom, rarely occurs (monthly) Moderate symptom, occurs occasionally (weekly) Severe symptom, occurs frequently (daily)
Gastrointestinal
bloating, constipation, diarrhea, IBS, acid reflux, other gut issue
Energy
Fatigue, Chronic fatigue, other energy issue
Hormones
Thyroid, Female Hormone Dysfunction, Male Hormone Dysfunction, other hormonal issue
Skin
Eczema, Psoriasis, Acne, other skin problems
Cardiovascular
Hypertension, High Cholesterol Levels, Other cardiovascular issue
Blood Sugar Abnormalities
Type 1 Diabetes, Type 2 Diabetes, Hypoglycemia, other blood sugar abnormality
Weight
Overweight, underweight, obese, other weight issue
Fertility
miscarriage, infertility, other fertility issue
Mental Health
anxiety, depression, other mental health issue
Liver/Gallbladder
Gallstones, hepatitis, fatty liver, other liver issue
Urinary
Kidney stones, other kidney issue
Sleep
Insomnia, other sleep issue
Pain
Headaches, Migraines, joint pain, arthritis, muscle pain, other pain
Immune System
Frequent illness or infection, History of Mononucleosis
Medications
Take prescription medications. Choose the amount of prescription medications you take.

CB Pillars

Optimize Nutrition

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
Microwaved Popcorn
Foods with Food Coloring
Hormone-treated Meats
MSG
Charred, grilled, blackened, or burnt food

Follow a Regimen

KEY (Regimen) 5 to 7 times per week 3 to 5 times per week 1 to 2 times per week never
At least 8 hours of sleep per night
Meditation, deep breathing, or stress-relieving practices
Drink half your weight in ounces of water daily
Good dental hygiene (flossing, etc.)
Sweat daily
Eat at least 3 servings of colorful fruits or vegetables
Have at least one bowel movement daily that is easy to pass, shaped like a banana, and sinks to the bottom of the toilet
Eat at least 2 servings of raw, uncooked fruits and vegetables daily

Keep It Clean

Toxic exposures Do not use at all Use 1-2 times monthly Use weekly Use daily
Do you use non-stick cookware?
Do you use plastic containers?
Do you drink unfiltered 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 eat rice? No Yes
Was your home built before 1978? No Yes
Do you have foam furniture? No Yes
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 (metal) dental fillings? No Yes
Do you see mold in your home or office? No Yes
Do you take medications?
Do you use non-organic cosmetic or personal care products?
Do you use dry cleaning?
Did your mom have amalgam fillings when she was pregnant with you? No Yes
Do you go to the firing range or shoot a gun frequently? Not at all Sometimes Frequently Very Frequently
Do you have tattoos? None 1-2 black tattoos 3-5 black tattoos to 1-2 colored tattoos Tattoos cover a large surface of the body, or have more than 3 colored tattoos
Do you use aluminum foil for cooking?

Move Your Body

Exercise

KEY (Regimen) 5 to 7 times per week 3 to 5 times per week 1 to 2 times per week never
Do cardio exercises for at least 30 minutes
Do stretching or yoga exercises for at least 15 minutes
Do strengthening exercises for at least 30 minutes

Body Assessment

High Moderate Low Very Low
Flexibility
Strength
Agility
Stamina

Be Calm, Be Happy

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

Trapped Emotions

Trapped Emotions None Low Moderate High
Do you have any unresolved trauma from your past?
Do you get angry often?
Do you suffer from depression?
Do you suffer from anxiety?
Do you get panic attacks?
Do you cry often?
Do you worry a lot?
Do you have difficulty in your relationships with others?

Detox Funnel

Gut

Upper GI

Upper GI No, symptom
does not occur
Yes, minor or mild symptom,
rarely occurs (monthly)
Moderate symptom,
occurs occasionally (weekly)
Severe symptom,
occurs frequently (daily)
Belching or gas within one hour after eating
Heartburn or acid reflux
Bloating within one hour after eating
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 No Yes
Dairy sensitivity No Yes
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

Kidney/Bladder

Kidney/Bladder No symptom does not occur Yes, minor or mild symptom, rarely occurs (monthly) Moderate symptom, occurs occasionally (weekly) Severe symptom, occurs frequently (daily)
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 kidney disease No Yes
In your last yearly labs, what was your eGFR? >90 or I don't know (0 points) 75-89 (1 point) 60-74 (2 points) <60 (3 points)

Liver

No, symptom does not occur Yes, minor or mild symptom, rarely occurs (monthly) Moderate symptom, occurs occasionally (weekly) Severe symptom, occurs frequently (daily)
Dry skin, itchy feet or skin peels on feet
Headache over eyes
History of hepatitis No Yes
Take prescription medications
Sensitive to chemicals (perfume, cleaning agents, etc.)
Sensitive to tobacco smoke
Exposure to diesel fumes
Hemorrhoids or varicose veins
Chronic fatigue or Fibromyalgia
Become sick if you were to drink wine or other alcohol No Yes
Easily intoxicated if you were to drink wine or other alcohol No Yes
Easily hung over if you were to drink wine or other alcohol No Yes
Alcohol per week <3 <7 <14 >14
Recovering alcoholic No Yes
Hives, Eczema, Psoriasis, or other skin conditions
Overweight or Obese
High cholesterol levels
For Males: Erectile Dysfunction, Have "Man Boobs", or other Male Hormone Dysfunction
For Females: Have PMS, Painful Periods, Endometriosis, Fibroids, or other Female Hormone Dysfunction
Low sex drive
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
Diagnosed with Thyroid Condition: Hashimoto's, Graves, Hypothyroidism, Hyperthyroidism
Headache if meals are skipped or delayed
Get "hangry" if you miss a meal
Shaky if meals delayed
Diagnosed with cardiovascular disease
High blood pressure
Oversweating problem
Difficulty sweating
Night sweats

Bile

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
Gallbladder attacks Never Years ago Within last year Within past 3 months
Gallbladder removed No Yes
Pain under right side of rib cage
Bitter taste in mouth, especially after meals
Constipation

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 Cleanbody 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, nutrition, and regenerative modalities.