Food Allgeries

Answer the questions below, using the symptom scale:

0=Never 1=Seldom 2=Occasionally 3=Frequently

4=Infrequently with severe symptoms 5=Almost always

Feel worse after eating

Poor memory

Insomnia

Canker or cold sores

Itchy anus

Fatigue

Learning disability

Chronic sore throat

Spastic/irritable colon

Muscular weakness

Genital itch

High blood pressure/ low blood pressure

Dark circles under eyes

Weight problems

Flu-like symptoms that are not the flu

Brain fogginess, dopiness, confusion

Total exhaustion

Inappropriate rage or emotional outbursts

Seizures

Infertility

Abdominal bloating or gas

Arthritis

Painful or irregular menstrual periods

Palpitations

Depression

Hyperactivity

Delusions

Diarrhoea and/or constipation

Muscle pains

Hives, rashes, acne

Anaemia, low white blood cell count, or low platelet count(blood "low" on lab tests)

Headaches

Mucus in throat, nose or sinuses

Crohn's disease, colitis

Bed-wetting

Asthma

Irritated eyes

Weakness

Headaches

Recurrent ear, sinus, or other respiratory infection

Indigestion

Frequent urination

Coughing

Phlebitis

Your Name

Email Address