Scooby Health MSQ Detoxification Questionnaire

  • DETOXIFICATION QUESTIONNAIRE

  • Today's Date*
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  • Date of Birth*
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  • Rate each of the following symptoms based on your typical health profile for the specified duration.*

  • 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

  • I. Medical Symptoms Questionnaire

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  • II. Xenobiotic Tolerability Test (XTT)

  • 1. Are you currently using prescription drugs?*
  • 2. Are you presenting taking one or more of the following over-the-counter drugs?
  • 3. If you have used or currently use prescription drugs, which of the following scenarios best represents you response to them?
  • 4. Do you currently use or within the last 6 months, have you regularly used tobacco products?*
  • 5. Do you have strong negative reactions to caffeine or caffeine containing products?*
  • 6. Do you commonly experience "brain fog," fatigue or drowsiness?*
  • 7. D you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?*
  • 8. Do you feel ill after you consume even small amounts of alcohol?*
  • 9. Do you have a personal history of:
  • 10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?*
  • 11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar vegetables, etc.?*

  • III. Alkalizing Assessment

  • 1. Do you have a history or currently have kidney dysfunction?*
  • 2. Have you ever been diagnosed with a condition known as hyperkalemia?*
  • 3. Are you currently on diuretics or blood pressure medication?*

  • Overall Score Tabulation

  • Should be Empty: