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Home > New Patient Center > Online Forms > Detoxification Questionaire
Please read the following symptoms and rate them based on how you have been feeling over the past 30 days.
Fill in the blanks using the appropriate numbers on the key below.
0 - No, Never, Almost Never Occurs
1 - Occasionally Occurs, Effect Not Severe
2 - Occasionally Occurs, Effect Severe
3 - Frequently Occurs, Effect Not Severe
4 - Frequently Occurs, Effect Severe
Please add the numbers from each section and writhe the total in the space provided under that section X Then add all the totals for each section together and put that total in the space below X