General Screening Questionnaire If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Doctor's Name: * Dr. Ping Jaa Dr. Paul Payton Dr. Jane Chapman Dr. David Jaa Patient First Name * Patient Surname * 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 Nausea or vomiting 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 Diarrhoea 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 Constipation 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 Bloated feeling 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 Belching or passing gas 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 Heart burn 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 Intestinal / stomach pain 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 EARS Itchy ears 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 Ear aches or infections 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 Drainage from ear 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 Ringing in ears 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 EMOTIONS Mood swings 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 Anxiety or nervousness 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 Anger or aggressiveness 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 Depression 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 ENERGY / ACTIVITY Fatigue or sluggishness 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 Apathy or lethary 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 Hyperactivity 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 Restlessness 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 EYES Watery or itchy eyes 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 Swollen or sticky eyelids 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 Bags under eyes 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 Blurred or tunnel vision 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 HEAD Headaches 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 Faintness 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 Dizziness 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 Insomnia 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 HEART Irregular heartbeat 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 Rapid or pounding heartbeat 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 Chest pain 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 JOINTS / MUSCLES Pain or aches in joints 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 Arthritis 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 Stiffness or limited movement 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 Pain or aches in muscles 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 Weakness or tiredness 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 LUNGS Chest congestion 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 Asthma or bronchitis 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 Shortness of breath 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 Difficulty breathing 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 MIND Poor memory 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 Confusion or poor comprehension 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 Poor concentration 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 Poor physical coordination 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 Difficulty making decisions 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 Stuttering or stammering 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 Slurred speech 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 Learning disabilities 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 MOUTH / THROAT Chronic coughing 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 Gagging 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 Sore throat or voice loss 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 Swollen or discoloured tongue 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 Canker sores 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 NOSE Stuffy nose 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 Sinus problems 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 Hayfever 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 Sneezing attacks 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 Excessive sweating 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 SKIN Acne 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 Hives or rashes 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 Hair loss 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 Hot flushes 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 Excessive Sweating 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 WEIGHT Binge eating / drinking 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 Craving certain foods 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 Excessive weight 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 Compulsive eating 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 Water retention 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 Underweight 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 OTHER Frequent illness 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 Frequent urination 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 Genital itch or discharge 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 Total COMMENTS: Have you ever been treated with antibiotics? Have you ever had a yeast infection? Do you eat or crave sweet foods? Do you have food allergies? Have you ever had food poisoning? Do you or have you consumed alcohol regularly? Have you ever taken Tagamet or Zantac? Do you take aspirin, panadeine or other pain killers? Do you take any other drugs regularly? Are you often in contact with organic chemicals? Do you react to strong perfumes, car exhaust, etc? Do you or have you ever smoked tobacco? Are you exposed to passive cigarette smoke? Do you consume caffeine? 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. Do you react when you consume caffeine? Are you sensitive to food additives like M.S.G.? Do you have a history of liver problems? If yes, describe: Are you currently taking any drugs? If yes, list: *
