Metabolic Detoxification Questionnaire

Metabolic Detoxification Questionnaire

Created by Metagenics.
Name

First NameLast Name
Email
example@example.com
I see the following inBalance doctor

Part 1: Symptoms
Rate each of the following symptoms based on the last week using the point scale below.

0 =Never or rarely have the symptom

1 =Occassionally 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

Digestive Tract

	0	1	2	3	4
Nauseau/ Vomiting
Diarrhea
Constipation
Bloated Feeling
Heartburn
Intestinal, stomach pain

Joints/ Muscle

	0	1	2	3	4
Pain or aches in joints
Arthritis, joint swelling
Stiff or limitation of movement
Pain or aches in muscles
Feeling of weakness or tired

Emotional

	0	1	2	3	4
Mood Swings
Anxiety, fear, nervousness
Anger, irritability, aggression
Depression

Weight/ Food

	0	1	2	3	4
Binge eating, drinking
Craving certain foods
Excessive weight
Compulsive eating, food addictions
Water retention
Underweight

Energy/ Sleep

	0	1	2	3	4
Fatigue, sluggishness
Apathy, lethargy
Hyperactivity
Restlessness, achiness
Sleep disturbances

Skin

	0	1	2	3	4
Acne
Hives, rashes, dry skin, redness
Hair loss
Flushing, hot flashes
Excessive sweating

Heart

	0	1	2	3	4
Irregular or skipped heartbeat
Rapid or pounding heartbeat
Chest pain

Other

	0	1	2	3	4
Frequent illness
Frequent or urgent urination
Genital itch or discharge

Respiratory

	0	1	2	3	4
Chest congestion
Asthma, bronchitis
Shortness of breath
Difficulty breathing

Eyes

	0	1	2	3	4
Watery or itchy eyes
Swollen, red, or sticky eyelids
Bags or dark circles under eyes
Blurred or restricted vision

Nose

	0	1	2	3	4
Stuffy nose
Sinus problems or dripping nose
Hay fever
Sneezing attacks
Excessive mucus

Mouth/ Throat

	0	1	2	3	4
Frequent, consistent coughing
Gagging, need to clear throat
Sore throat, hoarse, loss of voice
Swollen or discolored tongue, gums, lips
Canker sores, other mouth sores

Ears

	0	1	2	3	4
Itchy ears
Earaches, ear infections
Drainage from ear, waxy buildup
Ringing in ears, hearing loss

Head

	0	1	2	3	4
Headaches
Faintness or lightheadedness
Dizziness

Cognitive

	0	1	2	3	4
Poor memory, recall
Confusion, poor comprehension
Poor concentration
Poor physical coordination
Difficulty making decisions
Stuttering, stammering
Slurred speech
Learning disabilities

Alkalizing Assessment
1. Do you have a history of or currently have kidney dysfunction?

Yes (1pt)No (0pts)
2. Have you ever been diagnosed with hyperkalemia?

Yes (1pt)No (0pts)
3. Are you currently taking diuretics or blood pressure medication?

Yes (1pt)No (0pts)
Should be Empty: