A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z | 0-9 |

Detoxification questionaire

DETOXIFICATION QUESTIONAIRE

Patient Name: __________________________________________________
Date: _______________________________
Rate each of the following symptoms based on your typical health profile for the specified duration: Past month
Point Scale: 0 – Never or almost never have the symptom 1 – Occasionally have it, effect in not severe 2 – occasionally have it, effect is
severe

3 – Frequently have it, effect is not severe 4 – Frequently have it, effect is severe
I. Medical Symptoms Questionnaire (MSQ)
HEAD ______ Headaches
DIGESTIVE ______ Nausea, vomiting
______ Dizziness
______ Insomnia TOTAL ______
______ Bloated feeling
______ Watery or itchy eyes
______ Belching, passing gas
______ Swollen, reddened or sticky eyelids ______ Heartburn
______ Bags or dark circles under eyes
______ Intestinal/stomach pain
TOTAL ______
______ Blurred or tunnel vision TOTAL ______
JOINTS/ ______ Pains or aches in joints
EARS ______ Itchy Ears
______ Stiffness or limitation of movement
______ Drainage from ear
______ Feeling of weakness or tiredness
______ Ringing in ears, hearing loss
TOTAL ______
______ Pains or aches in muscles
TOTAL ______

NOSE ______ Stuffy Nose
WEIGHT ______ Binge eating/drinking
___________ Craving certain foods ______ Hay Fever
______ Sneezing attacks
______ Water retention
______ Excessive mucus formation
TOTAL _______
______ Underweight
______ Compulsive eating
MOUTH/ ______ Chronic coughing
TOTAL ______
______ Gagging, frequent need to clear throat ENERGY/ ______ Fatigue, sluggishness
ACTIVITY
Sore throat, hoarseness, loss of invoice ______ Swollen or discoloured tongue, gums, lips
______ Hyperactivity
______ Canker Sores TOTAL ______ ______ Restlessness TOTAL ______
SKIN ______ Acne
MIND ______ Poor Memory
______ Confusion, poor concentration ______ Hair Loss
______ Difficulty in making decisions
______ Flushing, hot flashes
______ Stuttering or stammering
______ Excessive sweating TOTAL _______
HEART ______ Chest Pain
______ Learning disabilities
______ Irregular or skipped heart beat ______ Poor concentration
______ Rapid or pounding heartbeat
______ Poor physical coordination
TOTAL _______
TOTAL _______
LUNGS ______ Chest congestion
EMOTIONS ______ Mood swings
______ Anxiety, fear, nervousness ______ Shortness of breath
______ Anger, irritability, aggressiveness
______ Difficulty breathing TOTAL _______ ______ Depression TOTAL _______
OTHER ______ Frequent illness
______ Frequent or urgent urination ______ Genital itch or discharge
TOTAL _______

GRAND TOTAL TOTAL _______

II. Xenobiotix Tolerability Test (XTT)
1. Are you presently using prescription drugs? 6. Do you commonly experience “brain fog”, fatigue, or If yes, how many are you currently taking? ______ ( 1 pt. each) 7. Do you develop symptoms on exposure to fragrances, exhaust 2. Are you presently taking one or more of the following over- Yes (1 pt.) No (0pt) Don’t know (0 pt) 8. Do you feel ill after you consume even small amounts of Yes (1 pt.) No (0pt) Don’t know (0 pt) 3. If you have used or currently using prescription drugs, which of the following scenarios best represents your response to them? Environmental and/or chemical sensitivities (5 pts) Experience side effects, drug (s) is (are) efficacious at lowered Experience side effects, drug (s) is (are) efficacious at usual Experience no side effects, drug (s) is (are) usually not 10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic Experience no side effects, drug (s) is (are) usually efficacious 4. Do you currently use or within the last 6 months had you 11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such wine, dried fruit, salad bar Yes (1 pt.) No (0pt) Don’t know (0 pt) 5. Do you have strong negative reactions to caffeine or caffeine Yes (1 pt.) No (0pt) Don’t know (0 pt) GRAND TOTAL TOTAL _______
III. Alkalizing Assessment
1. Do you have a history or currently have kidney dysfunction? 3. Are you currently on diuretics or blood pressure medication? 2. Have you ever been diagnosed with a condition known as Note: Prescribe non- alkalizing nutrients if patient answered yes OVERALL SCORE TABULATION
See doctor brochure for protocol suggestions. MSQ score: ________________________ (High >50; Moderate 15-49; Low <14) XTT score: _________________________ (High >10; Moderate 5-9; Low <4) Urinary pH: _______________________ Note: Patients with high MSQ but low XTT may be exhibiting pathology that is not related to toxic load. Other mechanisms should be considered such as inflammation/ immune / allergic gastrointestinal dysfunction, oxidative stress, hormonal / neuro-transmitter dysfunction, nutritional depletion, and/or mind body. Individualize support with specific medical foods, diet and/or nutraceuticals.

Source: http://www.healthinmotion.co.za/wp-content/uploads/2012/06/DETOXIFICATION-QUESTIONAIRE.pdf