DETOXIFICATION QUESTIONNAIRE Patient Name:
Rate each of the following symptoms based on your typical health profile for the specified duration: ❐ Past month
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) DIGESTIVE
Excessive mucus formation TOTAL ACTIVITY
Poor physical coordination TOTAL EMOTIONS GRAND TOTAL II. Xenobiotic Tolerability Test (XTT)
1. Are you presently using prescription drugs?
6. Do you commonly experience “brain fog,” fatigue, or drowsiness?
If yes, how many are you currently taking? ____ (1 pt. each)❐
7. Do you develop symptoms on exposure to fragrances, exhaust
2. Are you presently taking one or more of the following over-the
❐ 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.)
3. If you have used or currently use prescription drugs, which of the
following scenarios best represents your response to them:❐
❐ Multiple chemical sensitivity (5 pts.)
Experience side effects, drug(s) is (are) efficacious at lowered
Experience side effects, drug(s) is (are) efficacious at usual
❐ Alcohol or chemical dependence (2 pts.)
Experience no side effects, drug(s) is (are) usually not efficacious
11. Do you have a history of significant exposure to harmful chemicals
❐ Experience no side effects, drug(s) is (are) usually efficacious
such as herbicides, insecticides, pesticides, or organic solvents?
4. Do you currently use or within the last 6 months had you regularly
12. Do you have an adverse or allergic reaction when you consume
sulfite containing foods such as wine, dried fruit, salad bar
5. Do you have strong negative reactions to caffeine or caffeine
❐ Yes (1 pt.) ❐ No (0 pt.) ❐ Don’t know (0 pt.)
containing products?❐ Yes (1 pt.) ❐ No (0 pt.) ❐ Don’t know (0 pt.)
GRAND TOTAL: OVERALL SCORE TABULATION
detoxification questionnaire (MSQ and XTT)
MSQ SCORE _________ (High >50; moderate 15-49: Low <14)
XTT SCORE _________ (High >10; moderate 5-9: Low <4)
Functional Medicine Protocol MSQ Score XTT Score Description Medical Food Additional Nutraceutical Support
indicated symptoms of elevated toxic load imbalanced detoxifiers
Additional Symptom-Specific Support Nutraceutical Support
Water retention and/or frequent or urgent urination
Diarrhea, constipation, and/or intestinal/stomach pain
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.
Application for Inclusion of Zinc Sulfate in the WHO Model List of Essential Medicines WHO, Child and Adolescent Health Expert Committee on the Selection and Use of Essential Medicines Geneva, 7-11 March 2005 Application for Addition (zinc sulfate) Application for the Inclusion of Zinc Sulfate in the WHO Model List of Essential Medicines SUBMITTED BY: World Health Organization C
Adult Medical Questionnaire WELLSPRING FAMILY MEDICAL ASSOCIATES 48. Any other family history we should know about? ___________________________________________________________________ 49. What is the attitude of those close to you about your illness? ! FOR WOMEN ONLY (questions 50-58): !50.Have you ever been pregnant? (If no, skip to question 53.) ! Number of miscarriages _____ Number of a