General Screening Questionnaire

Fields marked with an * are required

Rate each of the following symptoms based upon your health profile for the last 30 days.

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
Blank = Not sure


DIGESTIVE TRACT

EARS

EMOTIONS

ENERGY / ACTIVITY

EYES

HEAD

HEART

JOINTS / MUSCLES

LUNGS

MIND

MOUTH / THROAT

NOSE

SKIN

WEIGHT

OTHER



LIVER DETOXIFICATION TEST (LDT) SCREENING QUESTIONS

A certain percentage of patients will experience reactions during the LDT. The reactions include, but are not limited to: shakiness, headaches, nausea, palpitations, light-headedness and sweating. The following questions will help isolate those patients who may experience these reactions.

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