hands   on health

 Food Sensitivity Testing

Questionaire of Symptoms

 

Name       …………………………………………….                Date …………………….

Address  ………………………………………………………  Age   …………………

                ………………………………………………………   Tel    …………………

Please underline where applicable

a) Overweight, underweight, fluctuating weight
b) Itching or burning skin, eczema, urticaria, dandruff, acne, varicose veins
c) Cramps, nausea, vomiting, diarrhoea, constipation, bloating, flatulence, colitis, ulcerative colitis,
     irritable bowel, colic, indigestion, anaemia, tingling in legs.
d) Weeping/itching eyes, visual problems, sensitivity to bright lights, burning or gritty eyes, cataract
e) Sneezing, sinusitis, runny nose, polyps, postnasal drip, hayfever, nose bleeds, poor tolerance to pain.
f) Ringing in ears, earache.
g) Sore throat, hoarseness, cough, catarrh, asthma, wheezing, bronchitis, breathlessness.
h) Cold/hot sweating extremities, chilblains, hot flushes.
i) Fast/slow pulse, high/low blood pressure, palpitations, unexplained anginal pain.
j) Dark puffy circles under eyes, constant bruising.
k) Painful irregular periods, PMT, thrush.
l) Frequent micturation, bed wetting, water retention, cystitis,  excessive sweating.
m) Backache, aching muscles or joints, fibrositis, arthritis, tingling in muscles.
n) Inexplicable fatigue, sleepiness, drowsiness after meals, waking up tired, lack energy
o) Insomnia, waking during night, poor sleep pattern.
p) Persistent tension/anxiety/nervousness, panic attacks, poor tolerance to pain.
q) Headaches, migraines, convulsions, blackouts, vertigo, dizzy spells, poor co-ordination.
r) Mental confusion, poor concentration, forgetfulness, depression, blank mind, difficulty in making
    decisions.
s) Hyperactivity, irritability, aggressiveness.
t) Delayed walking/ crawling/ talking, learning difficulties.
u) Inability to delay or miss a meal, obsessional eating, craving a specific food, constant snacking, poor
    appetite excessive thirst, addicted to sweet foods
v) Tender gums, bleeding gums, mouth ulcers, crack in lips, sore tongue, teeth grinding, tooth decay
w) White marks on nails, splitting nails, stria on skin, dry/flaky skin, pale in colour, red pimples on skin
x) Excessive hair loss, prematurely gray hair.
y) Little desire for sex,  infertility, heavy period or blood loss
z) Burning feet or tender heels,
aa) History of:  antibiotics, steroids
 

Blood group:

 

Any other symptoms/ named diseases:

 

Do you feel stressed?  Please list main causes.

 

Do you have frequent colds/ infections?

 

Do you take regular exercise?   Do you smoke?

 

What medicines, homeopathic remedies, herbal teas/remedies, vitamin or mineral supplements are you currently taking?

 

Is there any food you are avoiding?

 

Please list childhood infections

 

Questions for women:

Number children:    Are you pregnant?   How many weeks?

 

Do you take the pill?   If so, for how long? 

 

Are you trying to become pregnant?  Do you have stretch marks?

 

Are you post menopause?                             Do you experience symptoms related to the menopause?

 

 

Return  with a sample of hair to:  

Carol Carter, Hands-on-Health, Woodlinn, High Banton, Kilsyth G65 0RA        Tel 01236 822437

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