DETOXIFICATION QUESTIONNAIRE Patient Name Date Rate each of the following symptoms based on your typical health profile for the specified duration 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 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/THROAT Chronic coughing 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 LUNGS Chest congestion Asthma, bronchitis Shortness of breath Total DIGESTIVE TRACT Nausea, vomiting Diarrhea Constipation Bloated feeling Belching, passing gas Heartburn Intestinal/stomach pain Total JOINTS/ MUSCLE Pain or aches in joints 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/ ACTIVITY Fatigue, sluggishness 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 Genital itch or discharge Total GRAND TOTAL
