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How Do I Know If I have Food Sensitivities?

by in Personal Assessment Forms April 24, 2013

Have you experienced any of the following symptoms in the last 60 days:

Symptom Scoring System:
●○○○= No Symptoms (Zero Points)
○●○○= Experience Mild Symptoms (One Point)
○○●○= Experience Moderate Symptoms (Two Points)
○○○●= Severe Symptoms (Three Points)

If your score is over 40 we believe you should contact our office today for an assessment. Also, if any one symptom is severe enough, it may require consideration.

Digestive Symptoms Emotional/Mental
○○○○ Stomach Pains or Cramping
○○○○ Constipation
○○○○ Diarrhea
○○○○ Reflux or Heartburn
○○○○ Bloating
○○○○ Gas
○○○○ Nausea or Vomiting
○○○○ Depression
○○○○ Anxiety
○○○○ Mood Swings
○○○○ Irritability
○○○○ Poor Concentration
Weight Energy
○○○○ Inability to Lose Weight
○○○○ Food Cravings
○○○○ Binge Eating
○○○○ Water Retention
○○○○ Fatigue
○○○○ Hyperactivity
○○○○ Lethargy
○○○○ Restlessness
○○○○ Insomnia
Sinus/Respiratory Skin Disorders
○○○○ Stuffy or Runny Nose
○○○○ Asthma
○○○○ Chest Congestion
○○○○ Chronic Cough
○○○○ Wheezing
○○○○ Frequent Sneezing
○○○○ Eczema
○○○○ Dermatitis
○○○○ Excessive Sweating
○○○○ Rashes
○○○○ Hives
Head/Ears  Other Symptoms:
○○○○ Migraines
○○○○ Headaches
○○○○ Earaches
○○○○ Ear Infection
○○○○ Ringing in Ears
○○○○ Joint Pain
○○○○ Arthritis
○○○○ Irregular Heartbeat
○○○○ Chest Pains
○○○○ Muscle Aches
Eyes/Throat Total Score:_________
○○○○ Itchy Eyes
○○○○ Watery Eyes
○○○○ Sore Throat
○○○○ Persistent Canker Sores

 

 

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