Detox Questionnaire Name* First Last Email* Date Rate each of the following symptoms based on your typical health profile for the specified duration:*Past monthPast weekPast 48 hours0 – 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 severeHeadHeadachesFaintnessDizzinessInsomniaHead - TotalEYESWatery or itchy eyesSwollen, red, or sticky eyelidsBags or dark circles under eyesBlurred or tunnel visionEyes - TotalEARSItchy earsEaraches, ear infectionsRinging in ear, hearing lossDrainage from earEars - TotalNOSEStuffy noseSinus problemsHay feverExcessive mucous formationSneezing attacksTotal - NoseMOUTH / THROATChronic coughingGagging, frequent need to clear throatSore throat, hoarseness, loss of voiceSwollen or discoloured tongue, gums, lipsCanker soresTotal - MOUTH / THROATSKINAcneHives, rashes, dry skinHair lossFlushing, hot flashesExcessive sweatingSkin TotalHEARTIrregular or skipped heartbeatRapid or pounding heartbeatChest painHeart TotalLUNGSChest congestionAsthma, bronchitisShortness of breathDifficulty breathingLungs - TotalDIGESTIVE TRACTNausea, vomitingDiarrheaConstipationBloated feelingBelching, passing gasHeartburnIntestinal/stomach painTotal - DIGESTIVE TRACTJOINTS / MUSCLESPain or aches in jointsArthritisStiffness or limitation of movementFeeling of weakness or tirednessPain or aches in musclesTotal - JOINTS / MUSCLESWEIGHTBinge eating/drinkingCraving certain foodsExcessive weightWater retentionUnderweightCompulsive eatingTotal - WEIGHTENERGY / ACTIVITYFatigue, sluggishnessApathy, lethargyHyperactivityRestlessnessTotal - ENERGY / ACTIVITYMINDPoor memoryConfusion, poor comprehensionDifficulty making decisionsStuttering or stammeringSlurred speechLearning disabilitiesPoor concentrationPoor physical coordinationTotal - MINDEMOTIONSMood swingsAnxiety, fear, nervousnessAnger, irritability, aggressivenessDepressionEMOTIONS - TotalOTHERFrequent illnessFrequent or urgent urinationGenital itch or dischargeOTHER - TotalXENOBIOTIC TOLERABILITY TEST (XTT)1. Are you currently taking prescription drugs?*NoYes -1Yes - 2Yes - 3Yes - 42. Are you presently taking one or more of the following over-the-counter Cimetidine Acetaminophen Estradiol 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)Experience side effects; drug(s) is/are efficacious at usual dose(s)Experience no side effects; drug(s) is/are usually not efficaciousExperience no side effects; drug(s) is/are usually efficacious4. Do you currently use or within the last 6 months had you regularly used tobacco products?*YesNo5. Do you have strong negative reactions to caffeine or caffeine-containing products?*YesNoDon't know6. Do you commonly experience “brain fog,” fatigue, or drowsiness?*YesNo7. Do you develop symptoms on exposure to fragrances, exhaust fumes, or strong odours?*YesNoDon't Know8. Do you feel ill after you consume even small amounts of alcohol?*YesNoDon't Know9. Do you have a personal history of: Environmental and/or chemical sensitivities Chronic fatigue syndrome Multiple chemical sensitivity Fibromyalgia Parkinson’s type symptoms Alcohol or chemical dependence Asthma 10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides, or organic solvents?*YesNo11. Do you have an adverse or allergic reaction when you consume sulfite-containing foods such as wine, dried fruit, salad bar vegetables, etc.?*YesNoDon't KnowXTT Grand Total MSQ Score: 50+ = High 15-49 = Moderate 0-14 = Low XTT Score: 10+ = High 5-9 = Moderate 0-4 = Low MSQ Score XTT Score Description Recommendations 50 + 10 + High level of general symptoms and indicated symptoms of elevated toxic load 15-49 5-9 Moderate level of general symptoms with moderate symptoms of toxic load 0-14 0-4 Low level of general symptoms and minimal indicators of toxic load