Metabolic Detoxification Questionnaire 


Name *
Name
Phone *
Phone
Date
Date
Part 1: Symptoms
Rate each of the following symptoms based on the last week using the following point scale: 0-never or rarely have the symptom 1- occasionally have it, effect is not severe 2- occasionally have the symptom, effect is severe 3- Frequently have it, effect is not severe 4- frequently have it, effect is severe
Digestive Tract
Joints/Muscles
Emotional
Weight/Food
Energy/Sleep
Skin
Heart
Other
Respiratory
Eyes
Nose
Mouth/Throat
Ears
Head
Cognitive
PART 2
Xenobiotic Tolerability Test (XTT)
Are you presently using prescription drugs?
Are you presently taking one or more of the following over-the-counter drugs?
If you have used or are currently using prescription drugs, which of the following scenarios best represents your response to them?:
Do you currently (within the last 6 months) or have you regularly used tobacco products?
Do you have strong negative reactions to caffeine or caffeine-containing products?
Do you commonly experience "brain fog," fatigue or drowsiness?
Do you develop symptoms with exposure to fragrances, exhaust fumes, or strong odours?
Do you feel ill after you consume even small amounts of alcohol?
Do you have a personal history of:
(select all that apply)
Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?
PART 3
Alkalizing Assesment