DETOX QUESTIONNAIRE
Full Name
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Age
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Date of birth
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Married?
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Yes
No
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Who Lives With You?
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Work
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Retired?
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Yes
No
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Have you ever lived on or near a farm?
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Yes
No
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Are you on thyroid medication?
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Yes
No
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What problems do you take medications for
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How is your health?
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Have you ever lived near a big business?
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Yes
No
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Have you ever had a severe mold issue where you worked or lived?
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Yes
No
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Have you ever been near a fluorescent bulb that shattered?
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Yes
No
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Does poison ivy, oak or parsnips mess you up?
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Yes
No
Not Sure
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Are you frustrated, scared or angry a lot?
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Yes
No
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Do you smoke?
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Do you drink?
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Have you ever lived in a city?
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Yes
No
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Have you ever lived in a city where a business was investigated for polluting water or air?
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Yes
No
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For this section, 0 is excellent and 10 is the worst it could possibly be.
Allergies or Sensitivities? 0-10
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Do your joints hurt? 0-10
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How is your energy? 0-10
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How do you sleep? 0-10
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How is your digestion? 0-10
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How is your memory? 0-10
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Do you have Neuropathy? Y/N 0-10
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How healthy do you eat on 0-10?
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Do you have brain fog? 0-10
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