MENTAL HEALTH TOXICITY AND DRUG QUESTIONNAIRE

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PERSONAL DETAILS

PLEASE NOTE: Answer the following questions with a click in the ‘box’ after the question if it applies, otherwise leave it blank! Should only one of three answers in one question apply to you, click in the box. Note that a copy of your answered questionnaire will automatically be emailed to my office.

SECTION‐A : PYRROLURIA


 

SECTION‐B : HISTADELIC


 

SECTION‐C: NICTINAMIDE THERAPY


 

Do you have any of the following characteristics?

SECTION‐D: BRAIN ALLERGIES


 

SECTION‐E: GLUCOSE TOLERANCE CHECK


 

SECTION‐F: ESSENTIAL FATTY ACIDS (OMEGAS)


 

SECTION‐G: ENDOCRINE SYSTEM


 

SECTION‐H: GENERAL HEALTH


 

ALLOPATHIC MEDICATION (PRESCRIPTION)


 

SUPPLEMENTS (SELF MEDICATION)


 

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