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Allergies
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Please select 0-5 according to severity (0 none, 1 mild, 5 severe)
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Nasal Congestion
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Chronic Fatigue
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Watery, red itchy eyes
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Frequent sinus or ear infection
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Sneezing
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Frequent cold or sore throats
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Wheezing
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Trouble breathing
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Cough
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Poor memory or concentration
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Itching
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Hyperactivity
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Eczema
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Abdominal or cramping
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Hives
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Arthritis or muscle aching
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Headaches
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Asthma
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Runny Nose
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Mucus in throat
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Are there any foods that cause you problems?
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Symptoms
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Do you have history of allergies?
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Are your symptoms constant?
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Have you been allergy tested before?
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(IF yes) Did you receive allergy shots
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Does any medication give you relief of your allergy symptoms?
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If yes please name the medications
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Do you suffer from uncontrolled asthma or reduced lung function?
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Ever had a severe allergic reaction?
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Are you currently taking beta blockers?
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ANS
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Please select if you are experiencing symptoms Today, last 7-14 days, or rare/never
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Blurred Vision
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Elevated Blood Sugar
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Extreme Thirst
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Fatigue (tiredness)
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Increased Hunger
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Burning Sensation - Feet
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Painful contact w/ socks/bed sheets
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Pebble or Sand Like Sensation in Shoes
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Stabbing or electrical shock
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Pins and Needles Sensation (anywhere)
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Cold, clammy, pale skin (any time of day)
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Depression
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Dizziness or Lightheadedness
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Thirst
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Fainting
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Lack of Concentration
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Lack of Energy
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Nausea
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Rapid, Shallow Breathing
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Blood Clot in Vein
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Irregular heartbeat, too fast/slow
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Headaches
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Swelling of Ankles
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Pain in Calves
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Heartburn
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Shortness of Breath
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Frequent Urination
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Numbness & Tingling in Hands/Feet
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Difficulty Digesting Food
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Exercise Intolerance
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Sexual Difficulties
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Urinary Problems
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ANS
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ABI
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Have you ever been diagnosed with the following?
• • •
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Have you been diagnosed with?
• • •
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Have you ever had or currently have
• • •
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Have you been recently diagnosed w/ any?
• • •
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