Dr. Cory - Diet Detox Questionnaire

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Personal Information

Name

Date

Email

Please describe your typical diet and give me an idea of what you eat. Include beverages. This form is optional, but can give a lot of insight about your current state of health.

Diet Information

Breakfast

Lunch

Dinner

Snacks

Please indicate if you consume the following and how often, (daily, times/week, rarely, never). Please note if you have any particular reactions to these products.

Diet Information (cont.)

Yes No
Frequency

Yes No
Frequency

Yes No
Frequency

Yes No
Frequency

Yes No
Frequency

Diet Information (cont. 2)

Yes No
Frequency

Yes No
Frequency

Yes No
Frequency

Yes No
Frequency

Yes No
Frequency

Misc. Information

What is your occupation?

Have you had any known significant exposure to
harmful chemicals? (Solvents, pesticides, herbicides).

Yes No Don't know
If yes, which ones?

Do you have negative reactions to caffeine
or caffeine containing products?

Yes No

Do you feel ill after you consume
even small amounts of alcohol?

Yes No

Are you currently taking any prescriptions drugs?

Yes No
If yes, which ones?

Are you presently taking one or more
of the following over-the counter drugs?

Cimetidine (Tagament)
Acetaminophen (Tylenol)
Estradiol/Birth Control Pills

Do you commonly experience side
effects from prescription drugs?

Yes No

Do you develop symptoms on exposure to
perfumes, exhaust fumes or strong odors?

Yes No Don't know

Do you commonly experience 'brain fog',
fatigue or drowsiness?

Yes No

Do you have an adverse or allergic reaction when
you consume sulfite-containing foods such as wine,
dried fruit, salad bar vegetables, etc.?

Yes No Don't know

Do you currently use or within the last 6 months have you
regularly used tobacco products?

Yes No

© 2007 Dr. Cory Reddish, Licensed Naturopathic Physician | Admin

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