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Detoxification Questionnaire
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Detoxification Questionnaire
Detoxification Questionnaire
developer
2023-02-09T10:18:28-05:00
Name
Date
MM slash DD slash YYYY
Rate each of the following symptoms based on your typical health profile for the specified duration:
Past month
Past week
Past 48 hours
Point Scale:
0—
Never or almost never have the symptom
1—
Occasionally have it, effect is not severe 2—Occasionally have it, effect is severe
3—
Frequently have it, effect is not severe
4—
Frequently have it, effect is severe
HEAD
Headaches
Dizziness
Faintness
Insomnia
Total
EYES
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision
Total
EARS
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears
Hearing loss
Total
NOSE
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation
Total
MOUTH/THROAT
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores
Total
SKIN
Acne
Hives, rashes, dry skin
Excessive sweating
Hair loss
Flushing, hot flashes
Total
HEART
Chest pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Total
LUNGS
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing
Total
DIGESTIVE TRACT
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain
Total
JOINTS/MUSCLE:
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles
Total
WEIGHT
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating
Total
ENERGY/ACTIVITY
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness
Total
MIND
Poor memory
Confusion, poor comprehension
Difficulty in making decisions
Learning disabilities
Stuttering or stammering
Slurred speech
Poor concentration
Poor physical coordination
Total
EMOTIONS
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression
Total
OTHER
Frequent illness
Frequent or urgent urination
Genital itch or discharge
Total
Grand Total
Xenobiotic Tolerability Test (XTT)
ARE YOU PRESENTLY USING PRESCRIPTION DRUGS?
(Required)
Yes
No
How many prescription drugs you currently taking?
2. Are you presently taking one or more of the following over-the counter drugs?
Cimetidine (2 pts.)
Acetaminophen (2 pts.)
Estradiol (2 pts.)
3. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them:
Experience side effects, drug(s) is (are) efficacious at lowered dose(s) (3 pts.)
Experience side effects, drug(s) is (are) efficacious at usual dose(s) (2 pts.)
Experience no side effects, drug(s) is (are) usually not efficacious (2 pts.)
Experience no side effects, drug(s) is (are) usually efficacious (0 pt.)
4. Do you currently use or within the last 6 months had you regularly used tobacco products?
Yes (2 pts.)
No (0 pt.)
5. Do you have strong negative reactions to caffeine or caffeine containing products?
Yes (1 pts.)
No (0 pt.)
Don’t know (0 pt.)
6. Do you commonly experience “brain fog,” fatigue, or drowsiness?
Yes (1 pts.)
No (0 pt.)
7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?
Yes (1 pts.)
No (0 pt.)
Don’t know (0 pt.)
8. Do you feel ill after you consume even small amounts of alcohol?
Yes (1 pts.)
No (0 pt.)
Don’t know (0 pt.)
9. Do you have a personal history of
Environmental and/or chemical sensitivities (5 pts.)
Chronic fatigue syndrome (5 pts.)
Multiple chemical sensitivity (5 pts.)
Fibromyalgia (3 pts.)
Parkinson’s type symptoms (3 pts.)
Alcohol or chemical dependence (2 pts.)
Asthma (1 pt.)
10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
Yes (1 pts.)
No (0 pt.)
11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar vegetables, etc?
Yes (1 pts.)
No (0 pt.)
Don’t know (0 pt.)
Grand Total
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