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 severe2 – 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 throatENERGY/ ______ 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.
NATIONAL UNIVERSITY OF SINGAPORE NUS Business School Department of Marketing MKT3416 Business to Business Marketing INSTRUCTOR: Assoc Prof Ashok Charan Tel: 6516 7222 SESSION: SEMESTER I, 2010/2011 Course Objectives Business-to-Business (B2B) Marketing is designed to provide students with a basic understanding of the concepts of marketing in the context of other bus
Osteoporosis Questionnaire Name: ___________________________________________________________ Date: _________________Age: _____Sex: _____ Race: _____ Family Background (ie: German): _______________________________Peak Adult Height: __________ Office use only: Current Height: _______ Weight: __________ Osteoporosis History: Have you ever had a bone density test before? Yes: _____ No: