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