Allergy Questionnaire

PLEASE READ CAREFULLY

Check the appropriate answers – underscore or circle particular symptoms and/or level of severity. If you had a moderate to severe condition in the past but no longer have it, circle “in past”. Circle the symptom and put the approximate dates or age when you had it (if you can remember).

ALLERGY: 1. Have you had any of the following types of allergy testing?

2. Are you allergic to any foods?

If so, which ones:

3. Do you have inhalant allergies?

Yes
No
In the past
Don't know

4. List other allergies you have:

5. Have you ever had a serious allergic reaction?

If yes, to what?

Give approximate date & symptom:

What treatment did you receive?

6. Do you have a chronic sniffle or cough?

Yes
No
In the past

3. I am only interested in nutrient therapy.

True
False

4. I have no interest in drug therapy.

True
False

5. I would accept prescription drugs as a last resort.

True
False

6. I can be cured.

True
False

7. My condition can’t be cured but only relieved.

True
False

8. Are you willing to relearn how to eat?

DIET AND EATING DISORDER: 1.Do you have a history of a weight problem

Type:

2. Have you gained or lost 10% or more of your normal weight in a period of one year?

Yes
No
Gained No. of Kgs
Lost No. of Kgs

3. Do you follow a special diet?

Yes
No
In Past

6. Do you feel better or worse with exercise?

Better
Worse
Same

7. What is your current waist size and/or circumference?

8. Have you noticed a change in waist size and/or circumference? If so, how long ago did you notice the change taking place?

Select which style of eating represents you the most:

Sensory-spiritual (flavouring food with meaning)
Fresh food / Fast Food (eating mostly processed, high calorie foods, less fresh food)
Emotional eating (eating to manage feelings)
Food Fretting (judgemental thoughts and over concern with or about food)
Taste snacking (eating while doing other activities)
Eating Atmosphere (dining aesthetics and surroundings)
Social fare (eating alone vs with others)

Select how many times per week you eat the following items: Peas, bean or bean curd

Selected Value: 1

Nuts, seeds or peanut butter

Selected Value: 1

Raw green or yellow vegetables

Selected Value: 1

Cooked green or yellow vegetables

Selected Value: 1

Other raw vegetables

Selected Value: 1

Other cooked vegetables

Selected Value: 1

Citrus fruit, melon, strawberries

Selected Value: 1

Other raw and drier fruits

Selected Value: 1

Pasta, rice bread or rolls (white)

Selected Value: 1

Pasta rice bread or rolls (whole grain)

Selected Value: 1

Cooked cereal

Selected Value: 1

Ready to eat cereal

Selected Value: 1

Homemade pancakes waffles biscuits etc

Selected Value: 1

Items listed above from bakery

Selected Value: 1

Pastries (eg pies, cakes, cookies etc)

Selected Value: 1

Ice cream, custard, or pudding

Selected Value: 1

Low fat or skimmed milk and milk products

Selected Value: 1

Whole milk or milk products eg cheese

Selected Value: 1

Eggs

Selected Value: 1

Bacon or sausage

Selected Value: 1

Cold cuts, tongue, hot dogs

Selected Value: 1

Trimmed beef, lamb, or pork / ham

Selected Value: 1

Untrimmed beef, lamb or poultry

Selected Value: 1

Liver or organ meats

Selected Value: 1

Trimmed veal or poultry

Selected Value: 1

Untrimmed veal or poultry

Selected Value: 1

Fish or shellfish

Selected Value: 1

Fried foods

Selected Value: 1

Vegetable oils or margarine

Selected Value: 1

Butter or meat drippings

Selected Value: 1

Coffee tea or soft drinks

Selected Value: 1

Alcoholic beverages per week

Selected Value: 1

Water seltzer herb teas etc

Selected Value: 1

Candy, sugar, honey, sweetened items

Selected Value: 1

Salt, olives, pickles or salted snacks

Selected Value: 1

Artificial sweeteners

Selected Value: 1

Baked, broiled or steamed foods

Selected Value: 1

Do you binge with food?

If yes, how often?

Do you fast?

If yes, how often? (copy)

Do you buy products at a health food store?

Do you buy organic fruits and vegetables?

Do you try and avoid refined sugar?

Do you try to avoid cholesterol intake in food?

Allergy Questionnaire

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