detoxification Name * First Name Last Name Email * Phone * (###) ### #### Message Are you sensitive to fragrances and odors? * Yes No What about food-any sensitivities? * Yes No Sensitive to particular medications? * Yes No Do you get a bad reaction from MSG - monosodium glutamate-in food? * Yes No Do you have sensitivity to caffeine? * Yes No Have you ever been sick from exposure to chemicals? * Yes No Does cigarette smoke bother you or make you sick? * Yes No Are you sensitive to smog or air pollution? * Yes No Do you sometimes wake up in the morning feeling as if you have been drugged? * Yes No Ever have unexplained skin rashes? * Yes No Do you ever experience brain fog? * Yes No Do you feel a tingling in your hands or feet? * Yes No Is there a consistent ringing in your ears? * Yes No Do you experience unexplained muscle pain? * Yes No Thank you!