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Patient Name:
Rate each of the following symptoms based on your typical health profile for the specified duration: ❐ Past month Point Scale:
0Never or almost never have the symptom 1Occasionally have it, effect is not severe 2Occasionally have it, effect is severe
3Frequently have it, effect is not severe
4Frequently have it, effect is severe
I. Medical Symptoms Questionnaire (MSQ)
Excessive mucus formation TOTAL
Poor physical coordination TOTAL
II. Xenobiotic Tolerability Test (XTT)
1. Are you presently using prescription drugs? 6. Do you commonly experience “brain fog,” fatigue, or drowsiness? If yes, how many are you currently taking? ____ (1 pt. each)❐ 7. Do you develop symptoms on exposure to fragrances, exhaust 2. Are you presently taking one or more of the following over-the ❐ Yes (1 pt.) ❐ No (0 pt.) ❐ Don’t know (0 pt.) 8. Do you feel ill after you consume even small amounts of alcohol? ❐ Yes (1 pt.) ❐ No (0 pt.) ❐ Don’t know (0 pt.) 10. Do you have a personal history of ❐ Environmental and/or chemical sensitivities (5 pts.) 3. If you have used or currently use prescription drugs, which of the following scenarios best represents your response to them:❐ ❐ Multiple chemical sensitivity (5 pts.) Experience side effects, drug(s) is (are) efficacious at lowered Experience side effects, drug(s) is (are) efficacious at usual ❐ Alcohol or chemical dependence (2 pts.) Experience no side effects, drug(s) is (are) usually not efficacious 11. Do you have a history of significant exposure to harmful chemicals ❐ Experience no side effects, drug(s) is (are) usually efficacious such as herbicides, insecticides, pesticides, or organic solvents? 4. Do you currently use or within the last 6 months had you regularly 12. Do you have an adverse or allergic reaction when you consume sulfite containing foods such as wine, dried fruit, salad bar 5. Do you have strong negative reactions to caffeine or caffeine ❐ Yes (1 pt.) ❐ No (0 pt.) ❐ Don’t know (0 pt.) containing products?❐ Yes (1 pt.) ❐ No (0 pt.) ❐ Don’t know (0 pt.) GRAND TOTAL:
detoxification questionnaire (MSQ and XTT) MSQ SCORE _________ (High >50; moderate 15-49: Low <14) XTT SCORE _________ (High >10; moderate 5-9: Low <4) Functional Medicine Protocol
MSQ Score
XTT Score
Medical Food
Additional Nutraceutical Support
indicated symptoms of elevated toxic load imbalanced detoxifiers Additional Symptom-Specific Support
Nutraceutical Support
Water retention and/or frequent or urgent urination Diarrhea, constipation, and/or intestinal/stomach pain Note: Patients with high MSQ but low XTT may be exhibiting pathology that is not related to toxic load. Other mechanisms should be considered such as
inflammation/immune/allergic gastrointestinal dysfuntion, oxidative stress, hormonal/neurotransmitter dysfunction, nutritional depletion, and/or mind body.
Individualize support with specific medical foods, diet, and/or nutraceuticals.


Chp383903 65.83

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I am getting really bad mucus at the back of my throat which seems worse when I sit or lie down. What is causing this? Can you give me some advice? The explanation: An abundance of mucus in the back of the throat can be due to chronic rhinitis or acid reflux This is a common problem, and often a symptom that persists for years because patients have difficulty in obtaining a diagnosis, let al

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