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Kingston, ON
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Home
About
How it started
Our Team
Values
Book Now
Services
Make An Appointment
Metabolic Detoxification Questionnaire
Menu
Menu
Delivery
Workshops
Shop
Must Haves
Contact
Metabolic Detoxification Questionnaire
Name
*
Name
First Name
Last Name
Email Address
*
Phone
*
Phone
Country
(###)
###
####
Date
Date
MM
DD
YYYY
Part 1: Symptoms
Rate each of the following symptoms based on the last week using the following point scale: 0-never or rarely have the symptom 1- occasionally have it, effect is not severe 2- occasionally have the symptom, effect is severe 3- Frequently have it, effect is not severe 4- frequently have it, effect is severe
Digestive Tract
Nausea/Vomiting
0
1
2
3
4
Diarrhea
0
1
2
3
4
Constipation
0
1
2
3
4
Bloated Feeling
0
1
2
3
4
Heartburn
0
1
2
3
4
Intestinal, stomach pain
0
1
2
3
4
Joints/Muscles
Pain or aches in joints
0
1
2
3
4
Arthritis, joint swelling
0
1
2
3
4
Stiff or limitation of movement
0
1
2
3
4
Pain or aches in muscles
0
1
2
3
4
Feeling of weakness or tired
0
1
2
3
4
Emotional
Mood swings
0
1
2
3
4
Anxiety, fear, nervousness
0
1
2
3
4
Anger, Irritability, aggression
0
1
2
3
4
Depression
0
1
2
3
4
Weight/Food
Binge eating, drinking
0
1
2
3
4
Craving certain foods
0
1
2
3
4
Excessive Weight
0
1
2
3
4
Compulsive eating, food addictions
0
1
2
3
4
Water Retention
0
1
2
3
4
Underweight
0
1
2
3
4
Energy/Sleep
Fatigue, sluggishness
0
1
2
3
4
Apathy, lethargy
0
1
2
3
4
Hyperactivity
0
1
2
3
4
Sleep disturbances
0
1
2
3
4
Skin
Acne
0
1
2
3
4
Hives, rashes, dry skin, redness
0
1
2
3
4
Hair Loss
0
1
2
3
4
Flushing, hot flashes
0
1
2
3
4
Excessive Sweating
0
1
2
3
4
Heart
Irregular or skipped heartbeat
0
1
2
3
4
Rapid or pounding heartbeat
0
1
2
3
4
Chest pain
0
1
2
3
4
Other
Frequent Illness
0
1
2
3
4
Frequent or urgent urination
0
1
2
3
4
Genital itch or discharge
0
1
2
3
4
Respiratory
Chest congestion
0
1
2
3
4
Asthma, bronchitis
0
1
2
3
4
Shortness of Breath
0
1
2
3
4
Difficulty Breathing
0
1
2
3
4
Eyes
Watery or itchy eyes
0
1
2
3
4
Swollen, red, or sticky eyelids
0
1
2
3
4
Bags or dark circles under eyes
0
1
2
3
4
Blurred or restricted vision
0
1
2
3
4
Nose
Stuffy nose
0
1
2
3
4
sinus problems or dripping nose
0
1
2
3
4
Hay fever
0
1
2
3
4
Sneezing attacks
0
1
2
3
4
Excessive mucus
0
1
2
3
4
Mouth/Throat
Frequent, consistent coughing
0
1
2
3
4
Gagging, need to clear throat
0
1
2
3
4
Sore throat, hoarse, loss of voice
0
1
2
3
4
Swollen or discoloured tongue, gums, or lips
0
1
2
3
4
Canker sores, other mouth sores
0
1
2
3
4
Ears
Itchy eyes
0
1
2
3
4
Earaches, ear infections
0
1
2
3
45
Drainage from ear, waxy buildup
0
1
2
3
4
Ringing in ears, hearing loss
0
1
2
3
4
Head
Headaches
0
1
2
3
4
Faintness or lightheadedness
0
1
2
3
4
Dizziness
0
1
2
3
4
Cognitive
Poor memory, recall
0
1
2
3
4
Confusion, poor comprehension
0
1
2
3
4
Poor concentration
0
1
2
3
4
Poor physical coordination
0
1
2
3
4
Difficulty in making decisions
0
1
2
3
4
Stuttering, stammering
0
1
2
3
4
