Detox Questionnaire - Dr. Michael J. Hughes
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1
2Michael J. Hughes, D.C.
Comprehensive Chiropractic
610 W. Michigan Avenue
. Michael J Hughes,D.C., D.A.B.C.O.
Jackson, Michigan 49201
610 W. Michigan Ave.
784-9101
Jackson, MI 49201
DETOXIFICATION OUESTIONNAIRE
-
517-784-9101
Date:
_
Patient Name:
_
Rate each of the followingsymptoms based on your typical health profile for the specified duration:
CJ Past month
CJPast week
CJPast 48 hours
severe
Scale:
o-Never or alrrwst never have the symptom l-occasionally
have it, effect is not severe 2--Occasionally have it, effect is
Point
3-fuquently
have it, effect is not severe
4--Jilrequently have it, effect is severe
I. Medical Symptoms
Questionnaire
(MSQ)
HEAD
---
Headaches
DIGESTIVE
---
Nausea, vomiting
Faintness
---
TRACT
---
Diarrhea
---
Dizziness
---
Constipation
---
Insomnia
TOTAL
Bloated feeling
EYES
---
Watery or itchy eyes
---
Belching, passing gas
---
Swollen, reddened or sticky
Heartburn
---
eyelids
IntestinaVstomach pain
TOTAL
---
Bags or dark circles under eyes
JOINTSI
Pain or aches in joints
---
Blurred or tunnel vision
TOTAL
MUSCLE
Arthritis
---
EARS
Itchy ears
---
---
Stiffness or limitation of movement
Earaches, ear infections
---
---
Feeling of weakness or tiredness
Drainage from ear
---
---
Pain or aches in muscles TOTAL
---
Ringing in ears,
WEIGHT
---
Binge eating/drinking
hearing loss
TOTAL
---
Craving certain foods
---
NOSE
Stuffy nose
---
Excessive weight
---
Sinus problems
---
Water retention
---
Hay fever
---
Underweight
---
Sneezing attacks
Compulsive eating
TOTAL
Excessive mucus formation TOTAL
ENERGY!
---
Fatigue, sluggishness
MOUTBI
---
Chronic coughing
ACTIVITY
---
Apathy, lethargy
THROAT
---
Gagging, frequent need to
clear throat
---
Hyperactivity
---
Sore throat, hoarseness,
Restlessness
TOTAL
loss of voice
MIND
---
Poor memory
---
Swollen or discolored
---
Confusion, poor comprehension
tongue, gums, lips
---
Difficulty in making decisions
Canker sores
TOTAL
---
Stuttering or stammering
SKIN
---
Acne
---
Slurred speech
---
Hives, rashes, dry skin
---
Learning disabilities
Hair loss
---
---
Poor concentration
---
Flushing, hot flashes
---
Poor physical coordination TOTAL
Excessive sweating
TOTAL
EMOTIONS
---
Mood swings
HEART
Chest pain
---
---
Anxiety, fear, nervousness
---
Irregular or skipped heartbeat
---
Anger,irritability, aggressiveness
---
Rapid or pounding
---
Depression
TOTAL
heartbeat
TOTAL
OTHER
---
LUNGS
Frequent illness
---
Chest congestion
---
---
Frequent or urgent urination
Asthma, bronchitis
---
---
Genital itch or discharge
Shortness of breath
TOTAL
---
TOTAL __
Difficulty breathing
GRAND TOTAL
TOTAL __
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