Detox Questionnaire

Personal Information

Please describe your typical diet and give me an idea of what you eat. Include beverages. This form is optional, but can give a lot of insight about your current state of health.

Diet Information

Please indicate if you consume the following and how often, (daily, times/week, rarely, never). Please note if you have any particular reactions to these products.

Diet Information (cont.)

Alcohol :

Coffee :

Caffeinated Tea :

No

Frequency

Bread :

No Frequency

Sodas :

No Frequency

Tomatoes, Potatoes, Eggplant, Bell or Chili peppers :

No Frequency

Soy Products :

No Frequency

Milk/Cheese :

No Frequency

Baked Goods :

No Frequency

Sugar :

No

Frequency

Misc. Information

Have you had any known significant exposure to
harmful chemicals? (Solvents, cleaning chemicals, pesticides, herbicides).  Were you in NYC for 9-11?

No Don’t know If yes, which ones?

Do you have negative reactions to caffeine
or caffeine containing products?

No

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

No

Are you currently taking any prescriptions drugs?

No

If yes, which ones?

Are they efficacious?

Are you presently taking one or more
of the following over-the counter drugs?

Do you commonly experience side
effects from prescription drugs?

No

Do you develop symptoms on exposure to
perfumes, exhaust fumes or strong odors?

No Don’t know

Do you commonly experience ‘brain fog’,
fatigue or drowsiness?

No

Do you have an adverse or allergic reaction when
you consume sulfite-containing foods such as red wine,
dried fruit, salad bar vegetables, etc.?

No Don’t know

Do you currently use or within the last 6 months have you
regularly used or been exposed to tobacco products?

No

Do you commonly experience “brain fog,” fatigue, or drowsiness?

No Don’t know

Do you develop symptoms on exposure to fragrances, exhaust

fumes, or strong odors?

No Don’t know

If yes, which ones?

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

No Don’t know

If yes, which ones?

Do you have a personal history of

Environmental and/or chemical sensitivities, including mold?

(5 pts.)

Chronic fatigue syndrome

No

Don’t know

(5 pts.)

Multiple chemical sensitivity

No

Don’t know

If yes, which chemicals?

(5 pts.)
Fibromyalgia

No

Don’t know

(3 pts.)
Parkinson’s type symptoms

No

Don’t know

If yes, what precipitated them?

(3 pts.)
Alcohol or chemical dependence

No

(2 pts.)

Asthma or COPD

No

(1 pt.)

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