XENOBIOTIC TOLERABILITY TESTEnvironmental toxicity exposure comes through multiple and repeated sources. One's overall exposure and load of these toxins can create many different chronic symptoms and disease states. Your scoring of these questions can help us to determine if a specific course of detoxification would prove beneficial in helping you meet your wellness goals.Date MM slash DD slash YYYY Name First Last 1. Are you presently using any prescription drugs? No Yes if YES, how many prescription drugs? 2. Are you presently taking any of the following over-the-counter drugs? Acetaminophen Ibuprofen Naproxen Antacid for acid reflux, heartburn, ulcers Antihistamine Estradiol 3. If you have used, or are currently using prescription drugs, which of the following scenarios best represents your response to them? Experience side effects, drug/s is/are effective at lowered dose/s Experience side effects, drug/s is/are effective at usual dose/s Experience no side effects, drug/s is/are usually not effective Experience no side effects, drug/s is/are usually effective 4. Do you currently regularly use, or have used within the past 6 months Tobacco products Vape products 5.Do you have strong negative reactions to caffeine or caffeine containing products? Yes No Don't Know Do not use 6. Do you feel ill after you consume even small amounts of alcohol? Yes No Don't Know Do not use 7. Do you develop symptoms on exposure to fragrances, exhaust fumes, chemical cleaning or gardening agents or other strong odors? Yes No Don't Know 8. Do you commonly experience “brain fog”, fatigue or drowsiness? Yes No 9. Do you have a personal history of any of the following? Environmental and/or chemical sensitivities Multiple chemical sensitivities Chronic fatigue syndrome Fibromyalgia Parkinson’s or Parkinson’s-like symptoms Asthma or chronic breathing difficulties Alcohol and/or chemical dependency 10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides or organic solvents? Yes No 11. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar vegetables, packaged lunch meats, etc. Yes No Don't Know 12. Do you have any known food/environmental allergies or sensitivities? Yes No Don't Know If YES, please list:
