food sensitivity questionnaire

1. name: *
2. date: *
Please answer the following questions to the best of your ability. 
Do you you suffer from the following problems on a regular basis (i.e. more than 3 times per week)?  
section 1 - digestive symptoms
3. abdominal bloating/distension *
4. abdominal cramps *
5. abdominal or stomach pain *
6. burping after eating certain foods *
7. difficulty losing weight *
8. difficulty gaining weight *
9. enuresis (bed-wetting) *
10. excess wind (flatulence) *
11. gallbladder problems (difficulty digesting fats) *
12. gastro-oesophageal reflux disease (GORD) *
13. glue ear (otitis media) *
14. gritty feeling in the eyes *
15. haemorrhoids (piles) *
16. indigestion (recurring) *
17. inexplicable weight gain or weight loss *
18. irregular bowel motions (e.g. constipation or diarrhea) *
19. irritable bowel syndrome (IBS) *
20. itchy bottom *
21. itchy, red ears *
22. metallic taste in the mouth *
23. mouth ulcers *
24. nausea *
25. persistent need to clear your throat/sore throat *
26. post-nasal drip *
27. rhinitis (runny nose) *
28. sinusitis *
29. sneezing (frequent) *
30. water retention *
section 2 - mental, emotional, and nervous system symptoms
31. addictions *
32. aggressive outbursts *
33. attention deficit disorder/AD/HD *
34. anxiety *
35. behavioral problems *
36. blankness or momentary difficulty finding the right word(s) *
37. blurred vision *
38. brain fog *
39. clumsiness *
40. confusion *
41. constant hunger *
42. dark circles under your eyes *
43. depression *
44. dilated blood vessels in your cheeks and nose *
45. dizziness *
46. dyslexia *
47. fidgeting *
48. foggy head *
49. food cravings *
50. headaches *
51. hyperactivity *
52. inability to think clearly *
53. insomnia *
54. lack of motivation/get up and go *
55. migraines *
56. mood swings *
57. palpitations *
58. panic attacks *
59. phobias *
60. poor concentration *
61. racing pulse *
62. restless leg syndrome *
63. slurred speech *
64. spacey *
section 3 - overt physical signs and symptoms
65. abnormal physical weakness or tiredness *
66. aching muscles and joints for no good reason *
67. arthritis *
68. asthma *
69. chronic infections *
70. eczema *
71. fibromyalgia (diagnosed by a physical therapist or doctor) *
72. hives (urticaria) *
73. itching *
74. painful joints in which the pain moves from one joint to another *
75. painful joint not associated with excessive use *
76. psoriasis *
77. rheumatoid arthritis *
78. rough, dry skin *
79. spots or acne (that are/is not hormone-related) *
80. skin rashes (for no other known reason) *
81. wheezing *
Nutrition therapy is not intended as a diagnosis, treatment, prescription, or cure for any disease, mental or physical, and is not intended as a substitute for regular medical care.  This questionnaire is for informational purposes only.