Detox Questionnaire

Karen Vaughan, L.Ac., Registered Herbalist (AHG) posted this in on January 27th, 2010

Personal Information

Name

Date

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

Breakfast

Lunch

Dinner

Snacks

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 : Yes

Frequency

Coffee : Yes

Frequency

Caffeinated Tea :

Yes

Frequency

Bread :

Yes
No
Frequency

Sodas :

Yes
No
Frequency

Tomatoes, Potatoes, Eggplant, Bell or Chili peppers :

Yes
No
Frequency

Soy Products :

Yes
No
Frequency

Milk/Cheese :

Yes
No
Frequency

Baked Goods :

Yes
No
Frequency

Sugar :

Yes
No

Frequency

Misc. Information

What is your occupation?

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

Yes
No
Don’t know
If yes, which ones?

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

Yes
No

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

Yes
No

Are you currently taking any prescriptions drugs?

Yes
No

If yes, which ones?

Are they efficacious?

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

Cimetidine (Tagament)

Acetaminophen (Tylenol)

Estradiol/Birth Control Pills

Do you commonly experience side
effects from prescription drugs?

Yes
No

Do you develop symptoms on exposure to

perfumes, exhaust fumes or strong odors?

Yes
No
Don’t know

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

Yes
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.?

Yes
No
Don’t know

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

Yes
No

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

Yes
No
Don’t know

Do you develop symptoms on exposure to fragrances, exhaust

fumes, or strong odors?

Yes
No
Don’t know

If yes, which ones?

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

Yes
No
Don’t know

If yes, which ones?

Do you have a personal history of

Environmental and/or chemical sensitivities, including mold?

Yes

Don’t know

(5 pts.)

Chronic fatigue syndrome

Yes

Don’t know

(5 pts.)

Multiple chemical sensitivity

Yes

Don’t know

If yes, which chemicals?

(5 pts.)
Fibromyalgia

Yes

Don’t know

(3 pts.)
Parkinson’s type symptoms

Yes

Don’t know

If yes, what precipitated them?

(3 pts.)
Alcohol or chemical dependence

Yes

Don’t know

(2 pts.)

Asthma or COPD

Yes

(1 pt.)

Eat

1. Pasture raised or wild meat, poultry, fish, eggs, and any natural animal fat
2. Vegetables, including leaves, stems, bulbs, roots
3. Fruits and berries (includes avocados and olives)
4. Nuts such as almonds, walnuts, hazelnuts, pecans, coconut, etc.
5. Herbs and spices

Avoid/minimize

(in order of importance)

1. Sweeteners, including sugar (white, brown, organic, whatever), maple syrup, rice or agave syrup, etc.
2. Vegetable oils other than extra virgin olive, avocado, palm, and coconut.
3. Cereal grains and flour or grain products (bread, pasta, pastries, etc.) Especially avoid glutinous grains like wheat, barley, rye or triticale.
4. Dry legumes (beans and peas, including soy and peanuts)
5. Dairy products. If you take them, use goat or raw or both

(thanks to Rachel and Donald Matsez, authors of The Garden of Eating)

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