Detox Questionnaire | Natural Wellness By Karen

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.)

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