DETOXIFICATION QUESTIONNAIRE

Patient Name:

Date:

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

[ ] Past month [ ] Past week [ ] Past 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

I. Medical Symptoms Questionnaire (MSQ)

HEAD Headaches Faintness Dizziness Insomnia TOTAL _______

EYES Watery or itchy eyes ______ Swollen, reddened or sticky eyelids _______ Bags or dark circles under eyes

Blurred or tunnel vision TOTAL : _________

EARS Itchy ears ______ Earaches, ear infections Drainage from ear Ringing in ears, ________ hearing loss

TOTAL

NOSE ____Stuffy nose ____ Sinus problems _____ Hay fever Sneezing attacks Excessive mucus formation TOTAL ______

MOUTH/		Chronic coughing
THROAT		Gagging, frequent need to
		clear throat
		Sore throat, hoarseness,
		loss of voice
		Swollen or discolored
		tongue, gums, lips
		Canker sores TOTAL

SKIN		Acne
		Hives, rashes, dry skin
		Hair loss
		Flushing, hot flashes
		Excessive sweating TOTAL

HEART

Chest pain

Irregular or skipped heartbeat

Rapid or pounding heartbeat

TOTAL

DIGESTIVE Nausea, vomiting

TRACT Diarrhea

Constipation

Bloated feeling

Belching, passing gas

Heartburn

Intestinal/stomach pain TOTAL

JOINTS/ Pain or aches in joints

MUSCLE Arthritis

Stiffness or limitation of movement

Feeling of weakness or tiredness

Pain or aches in muscles TOTAL

WEIGHT Binge eating/drinking

Craving certain foods

Excessive weight

Water retention

Underweight

Compulsive eating TOTAL

ENERGY/ Fatigue, sluggishness

ACTIVITY Apathy, lethargy

Hyperactivity

Restlessness TOTAL __________

MIND Poor memory

Confusion, poor comprehension

Difficulty in making decisions

Stuttering or stammering

Slurred speech

Learning disabilities

Poor concentration

Poor physical coordination TOTAL

EMOTIONS ____Mood swings

Anxiety, fear, nervousness

Anger, irritability, aggressiveness

Depression TOTAL

OTHER

Frequent illness

Frequent or urgent urination

Shortness of breath

Difficulty breathing TOTAL

Genital itch or discharge TOTAL

GRAND TOTAL TOTAL

1. Are you presently using prescription drugs?

� Yes (1 pt.)

If yes, how many are you currently taking? (1 pt. each)

� No (0 pt.)

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

� Yes (1 pt.) � No (0 pt.)

7. Do you develop symptoms on exposure to fragrances, exhaust

fumes, or strong odors?

2. Are you presently 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 your response to them:

� Experience side effects, drug(s) is (are) efficacious at lowered dose(s) (3 pts.)

� Experience side effects, drug(s) is (are) efficacious at usual dose(s) (2 pts.)

� Experience no side effects, drug(s) is (are) usually not efficacious

(2 pts.)

� Experience no side effects, drug(s) is (are) usually efficacious

( 0 pt.)

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

� Yes (2 pts.) � No (0 pt.)

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

� Yes (1 pt.) � No (0 pt.) � Don't know (0 pt.)

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

� Yes (1 pt.) � No (0 pt.) � Don't know (0 pt.)

10. 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 pt.)

11. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?

� Yes (1 pt.) � No (0 pt.)

12. 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 pt.) � No (0 pt.) � Don't know (0 pt.)

GRAND TOTAL:

For Practitioner Use Only:

OVERALL SCORE TABULATION
Recommended protocols based on new detoxification questionnaire (MSQ and XTT) MSQ SCORE (High >50; moderate 15-49: Low <14) XTT SCORE (High >10; moderate 5-9: Low <4)
MSQ Score	XTT Score	Description		Functional Medicine Protocol
				Medical Food	Diet	Additional Nutraceutical Support
50 or >	10 or >	High level of general symptoms and indicated symptoms of elevated toxic load		Medical food for imbalanced detoxifiers	28-day elimination diet	Bifunctional, antioxidant, and chlorophyllin nutraceuticals
15-49	5-9	Moderate level of general symptoms with moderate symptoms of toxic load		Medical food for imbalanced detoxifiers	10-day elimination diet	Consider bifunctional, antioxidant, and chlorophyllin nutraceuticals
14 or <	4 or <	Low level of general symptoms and minimal indicators of toxic load				Maintenance
Additional Symptom-Specific Support
Symptom			Nutraceutical Support
Water retention and/or frequent or urgent urination			Kidney support nutraceuticals
Heartburn and/or intestinal/stomach pain			Functional dyspepsia nutraceuticals
Diarrhea, constipation, and/or intestinal/stomach pain			Probiotics

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/neurotransmitter dysfunction, nutritional depletion, and/or mind body. Individualize support with specific medical foods, diet, and/or nutraceuticals.

MET1229 8/05 Rev 9/05