Food Intolerance Questionnaire
Date: ______Name: ______Age: ______DOB: ______
Do you ever experience any of the following symptoms? DIGESTIVE TRACT Belching/burping Bloated Abdominal distension Cramps Gas - rectal Constipation Diarrhea Nausea Stomach pains Vomiting Lactose intolerance Heartburn, acid reflux, indigestion Mucousy stools
EARS Ear aches Ear infections Hearing loss Itchy ears Ringing in ears
EYES Blurred vision Dark circles Itchy eyes Sticky eyelids Swollen eyelids Watery eyes
EMOTIONS Aggressiveness Anxiety/fear Depression Irritability/anger Mood swings Location: 1400 Route 70, 2nd Floor, Cherry Hill NJ 08034 Phone (888)985-2727
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Nervousness
ENERGY & ACTIVITY Apathy/fatigue Hyperactivity Restlessness Sluggishness
HEAD Dizziness Faintness Headaches Lightheadedness
JOINT & MUSCLES Muscle ache Arthritis Feeling of weakness Limited movement Joint pain Stiffness
RESPIRATORY Asthma/bronchitis-chronic Chest congestion Difficulty breathing Shortness of breath resting or with mild exertion Wheezing Excessive mucous Hay fever Sinus problems Sneezing attacks Stuffy nose Nasal congestion Post nasal drip Nasal polyps Sinus pressure or pain
MIND Confusion Learning disabilities Poor concentration Poor memory/Brain fog Stuttering/stammering Forgetfulness
Location: 1400 Route 70, 2nd Floor, Cherry Hill NJ 08034 Phone (888)985-2727
www.renewus.com
MOUTH & THROAT Chronic coughing Gagging Clear throat often Sore throat Swollen tongue/lips/gums
SKIN Acne Dermatitis Eczema (red, dry patches) Excessive sweating Flushing/hot flashes Hair loss Itching Dry skin
WEIGHT Binge eating Compulsive eating Cravings Excessive weight Underweight Water retention Night eating
OTHER Chest pains Frequent illness General itching Irregular heartbeat Rapid heartbeat Urgent urination Loss of Taste or Smell
TURN PAGE OVER → PLEASE LIST FOODS THAT HAVE CAUSED PROBLEMS FOR YOU AND THE PROBLEM EACH FOOD CAUSED FOODS PROBLEMS/SYMPTOMS/RESULTS Have you ever had an anaphylactic reaction (a severe allergic reaction that needs to be treated right away)? YES NO If so, anaphylactic reaction to what?: ______
Location: 1400 Route 70, 2nd Floor, Cherry Hill NJ 08034 Phone (888)985-2727
www.renewus.com
Have you ever been diagnosed with any of these allergic conditions? YES NO Asthma Urticaria (hives/swelling on surface of skin) Rhinitis (chronic running nose) Venom Allergy (insects, snakes, bees, fire ants) Medication allergies Angioedema (hives/swelling under the skin) Latex allergy Eczema (itchy, red, cracked inflamed and/or rough skin)
FAMILY HISTORY OF ALLERGIES Mother Father Brother or sisters Other: ______
Patient Signature: ______Date: ______
Location: 1400 Route 70, 2nd Floor, Cherry Hill NJ 08034 Phone (888)985-2727
www.renewus.com