• DETOXIFICATION QUESTIONNAIRE

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • 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 (MSQ)

  • HEAD
    Rows
  • EYES
    Rows
  • EARS
    Rows
  • NOSE
    Rows
  • MOUTH/ THROAT
    Rows
  • SKIN
    Rows
  • HEART
    Rows
  • LUNGS
    Rows
  • DIGESTIVE TRACT
    Rows
  • JOINTS/ MUSCLE
    Rows
  • WEIGHT
    Rows
  • ENERGY/ ACTIVITY
    Rows
  • MIND
    Rows
  • EMOTIONS
    Rows
  • OTHER
    Rows

  • II. Xenobiotic Tolerability Test (XTT)

  • 1. Are you presently using prescription drugs?
  • 2. Are you presently 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 your response to them:
  • 4. Do you currently use or within the last 6 months had 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. Do 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?
  • 10. Do you have a personal history of
  • 11. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
  • 12. 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

    See doctor brochure for protocol suggestions.

    MSQ SCORE:{grandTotal60} (High >50; moderate 15-49: Low <14)

    XTT SCORE: {grandTotal38} (High >10; moderate 5-9: Low <4)

     

    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 dysfuntion, oxidative stress, hormonal/neuro-transmitter dysfunction, nutritional depletion, and/or mind body. Individualize support with specific medical foods, diet, and/or nutraceuticals.

  • Should be Empty: