Health History Questionnaire

Detoxination® Intake

Health History Questionnaire

A detailed intake designed to help us understand your health background, exposure history, lifestyle patterns, and readiness for personalized Detoxination® support.

Detailed intake Confidential review Personalized next steps
Why This Matters

A deeper look at the factors that may shape your Detoxination® plan

This questionnaire gathers important information about your medical history, symptoms, medications, lifestyle, occupational background, environmental exposures, and relevant activities. The goal is to better understand your situation before making recommendations about education, coaching, or next steps.

Not a diagnosis

This questionnaire is used for intake and educational planning. It is not a substitute for medical evaluation, diagnosis, or treatment from a licensed healthcare provider.

Health Background

Helps us understand your current health picture, past history, medications, sensitivities, and important considerations.

Exposure History

Reviews occupational, environmental, mold, chemical, military, firefighting, hobby-related, and other possible exposure patterns.

Program Readiness

Helps determine whether preparation, coaching, practitioner review, or additional caution may be appropriate before proceeding.

Confidentiality

Your information is handled with care

By submitting this Health History Questionnaire, you agree to the collection of health-related information needed to assess your suitability for Detoxination® support and to tailor services to your specific needs. We are committed to safeguarding your privacy and handling your information responsibly.

Before You Begin

Take your time and answer as thoroughly as possible

01

Be specific

The more detail you provide, the easier it is to understand your exposures, history, and support needs.

02

Unsure is acceptable

If you are uncertain about a question, say so. Uncertainty is still useful information.

03

Ask for help

If you need clarification while completing the questionnaire, reach out before guessing.

Start Intake

Complete the Health History Questionnaire

Please answer as accurately and completely as possible. This intake helps guide safer, more personalized recommendations.

✓

Smart Intake Logic

If you have already completed the Detox Screening Tool, duplicate questions within this Health History Questionnaire may be hidden based on your response to the DST completion checkbox.

This helps streamline the intake process while still allowing for a more detailed review of your health history, exposures, symptoms, medications, and lifestyle factors.

Name
To convert kilograms to pounds, multiply kg by 2.205
Biological Sex
Examples: Book, Facebook, YouTube, Search
I have read (check all that apply):
Check all that apply:
I have watched:
Are you a Facebook Group member?
Please describe your work environment. (optional)
Please describe your hobbies. (optional)
Have you previously completed the Detox Screening Tool?
Use this Detox Screening Tool to help determine whether DIY, Remote Coaching, or Practitioner care may be best for you.

Case Details

Have you been diagnosed with any of the following?
Check all that apply:
Check any exposures you believe may apply to you:
Have you ever had contrast dye for MRI scans?
Do you have a history of any of the following?
What are your symptoms?
How would you describe your bowel movements most of the time?
Do any of these apply?

Surgical Implants and Treatments

Do you currently have any metal-containing implants, hardware, dental materials, piercings or retained fragments in your body?
Were your mercury fillings / dental amalgams removed by:

Medications, Labwork and Surgeries

Sauna, Exercise and Protocol Considerations:

Have you ever experienced the flushing form of niacin (vitamin B3)?
Do you have a history of any of the following blood pressure issues? Check all that apply.
What is your usual blood pressure, if known?
Do you own a sauna?
Do you have regular access to one?
If yes, what type of sauna?
What format is your sauna?
Examples: Walking, Rebounding / mini trampoline, Stretching or gentle mobility, Resistance bands, Cycling, or Swimming

Lifestyle Factors

How would you describe your current level of physical activity?
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