|
| Understanding key contributors to immune health will help identify the best course of action for recovery of immune function. After reviewing this questionnaire with your health care provider, please refer to the Immune Foundations Patient Handbook for dietary, lifestyle and nutrient therapy recommendations. |
Please list your top 3
major health concerns in
order of importance: |
|
Do you tend to catch cold
easily or recover slowly
from illness? |
|
Have you been diagnosed
with a recent or chronic
infection (such as Lyme
disease, Epstein-Barr,
Candidiasis, herpes
simplex)? |
|
Do you suffer from
chronic fatigue, chronic
pain, fibromyalgia or
migraine headaches? |
|
Do you have unexplained
rashes, redness or
itching? |
|
Do you eat at least five
servings of fruits and
vegetables per day? |
|
Do you regularly eat at
restaurants or consume
prepared foods from the
grocery store? |
|
Do you exercise at least
five days per week? |
|
Do you have any known
allergies or
sensitivities to foods or
medications? |
|
Do you regularly have
less than one or more
than three bowel
movements per day? |
|
Do you experience
frequent heartburn,
burping, gas or bloating? |
|
Have you used antibiotic
medications within the
past two years? |
|
Do you consume alcohol,
antacids or
anti-inflammatory/pain
killer drugs regularly? |
|
Do you feel less able to
handle stress or
experience more stress
now than in the past? |
|
Do you experience mental
fogginess or have trouble
concentrating? |
|
Do you have trouble
falling or staying
asleep? |
|
Do you wake feeling
unrested or depend on
caffeine to keep yourself
going throughout the day? |
|
Do you have regular
exposure to exhaust
fumes, tobacco smoke,
pesticides, commercial
chemicals, Y Nrnpaint,
cleaning chemicals or
volatile fumes? |
|
Have you lived in a house
or worked in an office
environment with a
history of water damage
or known mold? |
|
Are you sensitive to
smells or fragrances? |
|
Do you have seasonal
allergies, asthma or an
autoimmune disease? |
|
Disclaimer: This tool does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment. Never ignore professional medical advice in seeking treatment because of something you have read here or anywhere online. If you think you may have a medical emergency, immediately call your doctor or dial 911. |