Scooby Health MSQ Detoxification Questionnaire

Today's Date*

Name*

First NameLast Name

Which Coach are you speaking with?*

Email

Email*

Date of Birth*

Rate each of the following symptoms based on your typical health profile for the specified duration.*

Past monthPast weekPast 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*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Headaches
Faintness
Dizziness
Insomnia

EYES*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Watery/itchy eyes
Swollen, reddened, or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

HEAD TOTAL*

EYES TOTAL*

EARS*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Itchy ears
Earaches/infections
Drainage from ears
Ringing in ear, hearing loss

EARS TOTAL*

NOSE*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Stuffy Nose
Sinus Problems
Hay fever
Sneezing attacks
Excessive mucus formation

NOSE TOTAL*

MOUTH/THROAT*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chronic coughing
Gagging, frequent throat clearing
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

MOUTH/THROAT TOTAL*

SKIN*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

SKIN TOTAL*

HEART*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Chest Pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat

HEART TOTAL*

LUNGS*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3- Frequently, not severe	4- Frequently, severe
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

LUNGS TOTAL*

DIGESTIVE TRACT*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

DIGESTIVE TRACT TOTAL*

JOINTS/MUSCLE*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles

JOINTS/MUSCLE TOTAL*

WEIGHT*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

WEIGHT TOTAL*

ENERGY/ACTIVITY*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

ENERGY/ACTIVITY TOTAL*

MIND*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Poor memory
Confusion poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination

MIND TOTAL*

EMOTIONS*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

EMOTIONS TOTAL*

OTHER*

	0-Never/almost never have the symptom	1-Occasionally, not severe	2-Occasionally, severe	3-Frequently, not severe	4- Frequently, severe
Frequent illness
Frequent or urgent urination
Genital itch or discharge

OTHER TOTAL*

GRAND TOTAL*

1. Are you currently using prescription drugs?*

Yes (1 pt)No (0 pt)

If yes, how many are you currently taking? (1 point each)*

Please type in the number of prescriptions you're taking

2. Are you presenting 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 you response to them?

Experience side effects, drug(s) is (are) efficacious at lowered does(s) (3 pts.)Experience side effects, drug(s) is (are) efficacious at usual does(s) (2 pts.)Experience no side effects, drug(s) is (are) not efficacious (2 pts.)Experience no side effects, drug(s) is (are) usually efficacious (0 pts.)

4. Do you currently use or within the last 6 months, have you regularly used tobacco products?*

Yes (2 pts.)No (0 pts.)

5. Do you have strong negative reactions to caffeine or caffeine containing products?*

Yes (1 pts.)No (0 pts.)Don't know (0 pts.)

6. Do you commonly experience "brain fog," fatigue or drowsiness?*

Yes (1 pts.)No (0 pts.)

7. D you develop symptoms on exposure to fragrances, exhaust fumes, or strong odors?*

Yes (1 pts.)No (0 pts.)Don't know (0 pts.)

8. Do you feel ill after you consume even small amounts of alcohol?*

Yes (1 pts.)No (0 pts.)Don't know (0 pts.)

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 pts.)

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 pts.)

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 pts.)Don't know (0 pts.)

GRAND TOTAL

1. Do you have a history or currently have kidney dysfunction?*

YesNo

2. Have you ever been diagnosed with a condition known as hyperkalemia?*

YesNo

3. Are you currently on diuretics or blood pressure medication?*

YesNo

MSQ SCORE*

(High >50; moderate 15-49: Low

XTT SCORE*

(High >10; moderate 5-9: Low

DETOXIFICATION QUESTIONNAIRE

I. Medical Symptoms Questionnaire

II. Xenobiotic Tolerability Test (XTT)

III. Alkalizing Assessment

Overall Score Tabulation