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Ahealthyview.com.au

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.

Source: http://ahealthyview.com.au/wp-content/uploads/2013/01/Detox-Questionnaire.pdf