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Age when symptoms first observed
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Skin
• • •
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General
• • •
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Eyes
• • •
|
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Headaches
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Nose
• • •
|
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Ears
• • •
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T/A (Age)
|
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Throat
• • •
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Cardiovascular
• • •
|
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Chest
• • •
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Stools
• • •
|
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G.I.
• • •
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Endocrine
• • •
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G.U.
• • •
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Females
• • •
|
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Musculoskeletal
• • •
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Psychiatric
• • •
|
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Neurological
• • •
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Seasons when symptoms are severe
• • •
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Alcohol Drinking Habits
• • •
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Smoking habits
|
|
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Chemicals that Cause Symptoms
• • •
|
|
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Current Living Environment
• • •
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|
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Prior Allergy History
• • •
|
|
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Other Reaction(s)
• • •
|
|
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Food Reactions (5-60 minutes after meals)
• • •
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Specific Foods causing reactions 1-2 hours
• • •
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Foods causing symptoms in 2 -24 hours
• • •
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