nelsonhealingcenter.org - Detoxification Questionnaire

Patient Name:

Date:

Date

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

Rows	0	1	2	3	4
Headaches
Faintness
Dizziness
Insomnia

TOTAL:

EYES

Rows	0	1	2	3	4
Watery or itchy eyes
Swollen, reddened or sticky eyelids
Bags or dark circles under eyes
Blurred or tunnel vision

TOTAL:

EARS

Rows	0	1	2	3	4
Itchy ears
Earaches, ear infections
Drainage from ear
Ringing in ears, hearing loss

TOTAL:

NOSE

Rows	0	1	2	3	4
Stuffy nose
Sinus problems
Hay fever
Sneezing attacks
Excessive mucus formation

TOTAL:

MOUTH/ THROAT

Rows	0	1	2	3	4
Chronic coughing
Gagging, frequent need to clear throat
Sore throat, hoarseness, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores

TOTAL:

SKIN

Rows	0	1	2	3	4
Acne
Hives, rashes, dry skin
Hair loss
Flushing, hot flashes
Excessive sweating

TOTAL:

HEART

Rows	0	1	2	3	4
Chest pain
Irregular or skipped heartbeat
Rapid or pounding heartbeat

TOTAL:

LUNGS

Rows	0	1	2	3	4
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

TOTAL:

DIGESTIVE TRACT

Rows	0	1	2	3	4
Nausea, vomiting
Diarrhea
Constipation
Bloated feeling
Belching, passing gas
Heartburn
Intestinal/stomach pain

TOTAL:

JOINTS/ MUSCLE

Rows	0	1	2	3	4
Pain or aches in joints
Arthritis
Stiffness or limitation of movement
Feeling of weakness or tiredness
Pain or aches in muscles

TOTAL:

WEIGHT

Rows	0	1	2	3	4
Binge eating/drinking
Craving certain foods
Excessive weight
Water retention
Underweight
Compulsive eating

TOTAL:

ENERGY/ ACTIVITY

Rows	0	1	2	3	4
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness

TOTAL:

MIND

Rows	0	1	2	3	4
Poor memory
Confusion, poor comprehension
Difficulty in making decisions
Stuttering or stammering
Slurred speech
Learning disabilities
Poor concentration
Poor physical coordination

TOTAL:

EMOTIONS

Rows	0	1	2	3	4
Mood swings
Anxiety, fear, nervousness
Anger, irritability, aggressiveness
Depression

TOTAL:

OTHER

Rows	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Genital itch or discharge

TOTAL:

GRAND TOTAL 1

GRAND TOTAL 2

GRAND TOTAL:

DETOXIFICATION QUESTIONNAIRE

I. Medical Symptoms Questionnaire (MSQ)

II. Xenobiotic Tolerability Test (XTT)

III. Alkalizing Assessment