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