MSQ - MEDICAL SYMPTOM/TOXICITY QUESTIONNAIRE

NAME: DATE:
The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness,
and helps you track your progress over time. Rate each of the following symptoms based upon your health profile for the past
30 days. If you are taking after the first time, record your symptoms for the last 48 hours ONLY.

POINT SCALE 2 = Occasionally have, effect is severe

0 = Never or almost never have the symptom 3 = Frequently have it, effect is not severe
1 = Occasionally have it, effect is not severe 4 = Frequently have it, effect is severe

DIGESTIVE TRACT HEAD MOUTH/THROAT

Nausea or vomiting Headaches Chronic coughing
Diarrhea Faintness Gagging, frequent need to clear throat
Constipation Dizziness Sore throat, hoarseness, loss of voice
Bloated Feeling Insomnia Swollen/discolored tongue, gum, lips
Belching, or passing gas Total Canker sores
Hearburn Total
Intenstinal/Stomach Pain HEART
Total Irregular or skipped heartbeat NOSE
Rapid or pounding heartbeat Stuffy nose
EARS Chest pain Sinus problems
Itchy ears Hay fever
Total
Earaches, ear infections Sneezing attacks
Excessive mucus formation
Drainage from ear JOINTS/MUSCLES
Pain or aches in joints Total
Ringing in ears, hearing loss
Arthritis
Total
Stiffness or limitation of movement SKIN
Acne
EMOTIONS Pain or aches in muscles
Feeling of weakness or tiredness Hives, rashes, or dry skin
Mood Swings Hair loss
Anxiety, fear or nervousness Total Flushing or hot flashes
Anger, irritability, or aggressiveness Excessive sweating
LUNGS
Depression Chest congestion Total
Total Asthma, bronchitis
WEIGHT
Shortness of breath
ENERGY/ACTIVITY Difficult breathing
Binge eating/drinking
Craving certain foods
Fatigue, sluggishness Total Excessive weight
Apathy, lethargy Compulsive eating
Hyperactivity MIND Water retention
Restlessness Poor memory Underweight
Confusion, poor comprehension
Total Total
Poor concentration
Poor physical coordination OTHER
EYES
Difficult in making decisions Frequent illness
Watery or itchy eyes Stuttering or stammering Frequent or urgent urination
Swollen, reddened or sticky eyelids Slurred speech Genital itch or discharge
Bags or dark circles under eyes Learning disabilities
Total
Blurred or tunnel vision (does not Total
include near-or-far sightedness)
Total
Grand Total:

KEY TO QUESTIONNAIRE
Add individual scores and total each group. Add each group scores and give a grand total.
• Optimal is less than 10 • Mild Toxicity: 10-50 • Moderate Toxicity: 50-100 • Severe Toxicity: over 100
 RECOMMENDATIONS

PHASE 1:
NutriClear® Plus is a science-based metabolic cleanse program that
supports the body’s detoxification processes. This powerful combination
of micronutrients, NitroGreens®, fiber, fruit and vegetable extracts
supports safe and effective detoxification.

• NutriClear® Plus Organic Pea 15 Days 30 Days

• NutriClear® Plus Collagen 15 Days 30 Days

WHAT TO EXPECT WHEN DETOXING:

Day 1-3 Day 4-14
• Lightheadedness / Headaches - This is more • Clearer thinking
common for patients with a history of blood • Lighter feeling in the gut
sugar imbalances, or from caffeine withdrawals. • More energy, but don’t overdo it
• Focus on preparing one meal per day with • Increased awareness of how different foods affect you
unlimited snacks approved by the Metabolic
• More confidence in yourself as you begin to feel
• Cleanse Diet, listed in the guidebook.
better from making these lifestyle changes
Possible increased urination

PHASE 2:
Most people feel great after 15 days on the NutriClear® Plus
Metabolic Cleanse Program. As a way to continue the dietary
and lifestyle changes that have provided clinical benefits, we
recommend the MetabolicBiome™ Plus 7-Day Program.

Duration of Phase 2: Recommended Protein:

1 week MetabolicBiome™ Plus Collagen Vanilla
2 weeks MetabolicBiome™ Plus Collagen Chocolate
3 weeks MetabolicBiome™ Plus Whey Vanilla
4 weeks MetabolicBiome™ Plus Pea Vanilla

Other Notes from Masami & Chris' Experience

• Our personal preference is the Collagen option, as pea protein can be harder to digest for many people.
o Also, Collagen is an essential protein that every tissue of your body requires (esp. skin, hair, bones,
joint, teeth, GI tract, etc.)
• We have found it best to be flexible with using the NutriClear Plus powder pouches during the Cleanse.
o For example, if you are a smaller person, you may only want to take 1/2 of a pouch twice daily with
one supplement packet, and extend the cleanse to 30 days (this is what Masami does).

THE CONTENTS PROVIDED IN THIS DOCUMENT ARE INTENDED AS AN EDUCATIONAL RESOURCE FOR LICENSED HEALTHCARE PROFESSIONALS AND ARE TO BE USED
AS A SUGGESTED GUIDELINE (NOT A DIAGNOSTIC TOOL) WHEREBY PRACTITIONERS CAN TAILOR RECOMMENDATIONS TO THE INDIVIDUAL NEEDS OF EACH PATIENT.