Test Yourself For Food Allergies


Using the scale to the right, rate each of your symptoms based upon how you have been feeling during the past 30 days.

0 = never or almost never have the symptom.

1 = occasionally have it, effect is not severe

2 = occasionally have it, effect is severe.

3 = frequently have it, effect is not severe

4 = frequently have it, effect is severe.

 

Please print this form out and fill in accordingly

 

Digestive Track

__Nausea & vomiting

__Diarrhea

__Constipation

__Bloated feeling

__Belching or passing gas

__Stomach pains or cramps

__Heartburn

__Blood and/or mucous in stools

__Total

 

Joints & Muscles

__Pains or aches in joints

__Arthritis

__Stiffness or limitation of movement

__Pain or aches in muscles

__Feeling of weakness or tiredness

__Swollen tender joints

__Growing pains in legs

__Total

 

Head

__Headaches

__Faintness

__Dizziness

__Insomnia, sleep disorder

__Facial flushing

__Total

 

Mouth & Throat

__Chronic coughing

__Gagging, frequently clearing throat

__Sore throat, horseness, loss of voice

__Swollen or discolored tongue

__Canker sores

__Itching on roof of mouth

__Total

 

Weight

__Binge eating/drinking

__Craving certain foods

__Excessive weight

__Compulsive eating

__Water retention

__Total

 

Eyes

__Watery or itchy eyes

__Red, swollen or sticky eyelids

__Bags or dark circles under eyes

__Blurred or tunnel vision

__Total

 

Nose

__Stuffy nose

__Chronically red, inflamed nose

__Sinus problems

__Hay fever

__Sneezing attacks

__Excessive mucous formation

__Total

 

Emotions

__Mood Swings

__Anxiety, fear, nervousness

__Anger, irritability, aggressive

__Argumentative

__Frustrated, cries often

__Depression

__Total

 

Mind

__Poor memory

__Difficulty completing projects

__Difficulty with mathematics

__Underachiever in school

__Poor/short attention span

__Confusion

__Easily distracted

__Difficulty making decisions

__Learning disabilities

__Total

 

Lungs

__Chest congestion

__Asthma, bronchitis

__Shortness of breath

__Difficulty in breathing

__Persistent cough

__Wheezing

__Total

Skin

__Acne

__Itching

__Hives, rash, dry skin

__Hair loss

__Flushing or hot flashes

__Total

 

Ears

__Itchy ears

__Ear aches, ear infections

__Drainage from ear

__Ringing in ears

__Hearing loss

__Reddening of ears

__Total

 

Heart

__Irregular or skipped heartbeat

__Rapid or pounding heartbeat

__Chest Pain

__Total

 

Energy & Activity

__Apathy, lethargy

__Attention deficit

__Fatigue

__Hyperactivity

__Restlessness

__Poor physical coordination

__Stuttering or stammering

__Slurred speech

__Total

 

Other

__Frequent illness

__Frequent or urgent urination

__Genital itch or discharge

__Anal itching

__Total

 

 

____Grand Total

 

Note:  If your total in any one category exceeds 10, or your grand total exceeds 50, we strongly recommend you get an IgG Food Sensitivity Test.  

 

 

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