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 Date Format: MM slash DD slash YYYY Name First Last 1. Are you presently using any prescription drugs?NoYesif 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/sExperience side effects, drug/s is/are effective at usual dose/sExperience no side effects, drug/s is/are usually not effectiveExperience no side effects, drug/s is/are usually effective4. Do you currently regularly use, or have used within the past 6 monthsTobacco productsVape products5.Do you have strong negative reactions to caffeine or caffeine containing products?YesNoDon't KnowDo not use6. Do you feel ill after you consume even small amounts of alcohol?YesNoDon't KnowDo not use7. Do you develop symptoms on exposure to fragrances, exhaust fumes, chemical cleaning or gardening agents or other strong odors?YesNoDon't Know8. Do you commonly experience “brain fog”, fatigue or drowsiness?YesNo9. Do you have a personal history of any of the following?Environmental and/or chemical sensitivitiesMultiple chemical sensitivitiesChronic fatigue syndromeFibromyalgiaParkinson’s or Parkinson’s-like symptomsAsthma or chronic breathing difficultiesAlcohol and/or chemical dependency10. Do you have a history of significant exposure to harmful chemicals such as herbicides, insecticides, pesticides or organic solvents?YesNo11. 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.YesNoDon't Know12. Do you have any known food/environmental allergies or sensitivities?YesNoDon't KnowIf YES, please list: This iframe contains the logic required to handle Ajax powered Gravity Forms.