Determine Food Allergies & Chemical Sensitivities

Directions: Please answer all of the questions to the best of your ability. Check only those which apply to you. If you have any of the following symptoms, you may have a nutritional or immunological disorder. Please note this questionnaire is not intended to diagnose, treat, or prescribe for any disease. It is meant as an adjunct to your nutritional care.

SECTION 1

 Eyes-Ears
 Ear Infections, Tubes
 Eyes: puffy or dark circles
 Eyes: black floaters or white flashing lights
 Eyes: watery or itchy

Foods
 Sensitive to Nuts, Seeds, or Beans
 Sensitive to Seafood
 Sensitive to Dairy Products

Digestive
 Abdominal cramps
 Diarrhea or loose stools
 Diverticulitis, Colitis, Ileitis, IBD
 Gall stones, Gallbladder disease
 Irritable Bowel Syndrome

Miscellaneous
 Aero allergies to pollen, dust, mold, grass, ragweed, animals
 Headaches, Migraines
 Swelling, Water retention

Musculo-Skeletal
 Arthritis, Joint pains
 Muscle aches or spasms

Respiratory
 Asthma, Bronchitis
 Laryngitis, Sore throat
 Rhinitis, runny or stuffy nose, mucous

Skin
 Face: Rosacea
 Eczema, Hives, Rashes
 Red flushing cheeks or ears

Urinary
 Bedwetting
 Urinary Frequency

SECTION 2

What is your blood type?

Blood type A
 Blood type B
 Blood type O
 Blood type AB

SECTION 3

Autoimmune Disorder
 Addison's Disease
 Diabetes
 Endometriosis
 Fibromyalgia
 Hashimoto's Thyroiditis
 Lupus
 Multiple Sclerosis
 Rheumatoid Arthritis
 Sjogren's Syndrome

Cardiovascular
 Chest pains
 Pulse races after meals

Digestive
 Abdominal cramps
 Diarrhea or loose stools
 Diverticulitis, Colitis, Ileitis, IBD
 Gall stones, Gallbladder disease
 Irritable Bowel Syndrome

Eyes-Ears
 Ear Infections, Tubes
 Ringing ears
 Eyes: puffy or dark circles under
 Eyes: black floaters, flashing white lights
 Sensitivity to light or sound

Foods
 Food cravings, Bingeing
 Sensitivity to Dairy Products
 Sensitivity to Eggs
 Sensitivity to Grains, particularly gluten
 Sensitivity to Red Meats

General
 Fatigued, Drowsy
 Swelling, Water retention

Musculo-Skeletal
 Arthritis, Joint pains
 Muscle aches or spasms

Neurological
 Depression, Crying
 Headaches, Migraines
 Hyperactivity, ADHD
 Irritability, Anxiety
 Learning disorder, PDD
 Memory loss, confusion, dull spacey feeling

Reproductive
 Female: Vaginitis
 Male: Prostatitis

Urinary
 Bedwetting
 Kidney or bladder infections
 Urinary Frequency

SECTION 4

 Are you sensitive to any of the following?

Ingested Foods & Drugs
 Food additives, preservatives, sweeteners (sulfites, MSG, BHT, sorbitol, etc.)
 Food dyes (red, yellow, blue, green)
 Spices or herbs
 Medications, drugs, hormones
 Sugars: cane sugar, corn sugar, maple syrup, molasses, honey
 Nightshades: tomato, potato, eggplant, bell pepper, cayenne pepper, tobacco
 Tummy aches or headaches after ingesting any of the above

Fumes
 Fragrances: perfume, cosmetics, shampoo, conditioners, hair spray, lotions
 Petrochemicals: gasoline, paints, thinner, varnish
 Cleaners: soaps, detergents, ammonia
 Tobacco smoke
 Neurotoxins: insecticides, herbicides
 Formaldehydes: new carpets, fabrics, buildings
 Difficulty breathing after exposure to any of the above

Contact Allergies
 Plants: Poison ivy, poison oak, poison sumac
 Foods touched: shrimp, crab, etc.
 Cosmetics: make-up, shampoos, conditioners, hair sprays, lotions
 Plastics: vinyl, latex, silicone
 Swelling or rash at the site of contact with any of the above

Symptoms
Have you (or your child if you are responding for your child) had any of these symptoms?

Aggression, threats
 Behavior problems with other children or teachers
 Crying, screaming, hysteria, throwing self on ground
 Developmental delays: ADHD, ADD, PDD, learning disabilities, autism, epilepsy
 Fear, paranoia
 Headaches, tummy aches, feel poisoned, kidney pains, acne or rashes
 Hitting, kicking, biting, spitting
 Hyperactivity, mania

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