Dayton Ear, Nose
& Throat Surgeons, Inc.

John H. Boyles, M.D.         James J. Howard, M.D.         William E. Rogers, M.D.

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Food Allergy Questionnaire

Am I allergic?

To find out, simply answer the 19 Yes or No questions below by clicking the Yes answer for any question you feel describes your situation. When you are finished, click the Submit button at the bottom of the page.

1. Are there any foods or beverages that you crave or eat frequently? Yes   No
2. Are there any foods or beverages that you dislike? Yes   No
3. Are you awakened between the hours of 1:00 a.m. and 5:00 a.m. with the following symptoms: headache, dizziness, stomach cramps, bloating, or dry cough? Yes   No
4. Do you or any member of your family have hayfever, asthma, hives, chronic skin condition, migraine headaches, or colitis? Yes   No
5. During childhood did you have any of the following: Eczema, hayfever, asthma, food feeding problems? Yes   No
6. Do you ever have itching of the skin, plate or roof of you mouth or skin rash? Yes   No
7. Do you ever frequently notice swelling of your ankles, feet, hands, or face? Yes   No
8. Do you have marked fatigue two to three hours after meals? Yes   No
9. Do you eat snacks frequently between meals? Yes   No
10. Do you have excessive chilling when a sudden change in temperature occurs? Yes   No
11. Do you have frequent headaches or “Migraine”? Yes   No
12. Do you experience belching, or abdominal distention, bloating or cramps following meals? Yes   No
13. Have you noticed numbness of the face, arms, or legs at periodic intervals for no apparent cause? Yes   No
14. Do you have drowsiness, headache or bloating following the ingestion of a cocktail, glass of beer or glass of wine? Yes   No
15. Do you have alternating constipation and diarrhea? Yes   No
16. Do you have joint or muscle pain or stiffness? Yes   No
17. Do you have fluctuating vision? Yes   No
18. Do you have recurring fungal infections (vaginitis, athlete’s foot, jock itch, or ring worm)? Yes   No
19. Do you have fluctuating ringing in the ears or dizziness? Yes   No