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Food Allergy/Sensitivity Questionnaire

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Question 1 of 47

Name

Question 2 of 47

Date

Question 3 of 47

Occupation

Question 4 of 47

D.O.B.

Question 5 of 47

Age

Question 6 of 47

Address

Question 7 of 47

Have you or anyone in your immediate family (parents, grandparents, aunts, uncles, cousins, children) ever been known to suffer from allergies of any kind? List Who

Question 8 of 47

List any foods or beverages that disagree with you?

Question 9 of 47

Are there any foods, beverages or supplements that you take at least once a day, every day?

Question 10 of 47

Would you feel deprived of any foods or beverages if you were unable to obtain them? Which food(s)?

Question 11 of 47

List any foods or beverages that you crave for at any time?

Question 12 of 47

Do you eat regular meals?

Question 13 of 47

Do you get headaches, feel unwell or get irritable if you miss a meal?

Question 14 of 47

Do you snack or nibble foods between meals? Which food(s)?

Question 15 of 47

Are there any foods or beverages that you take more often or in larger quantities than anything else? List

For your average day, please check the appropriate column for Never, Infrequently, Sometimes, Regularly, at least Daily

Question 17 of 47

Milk

A

Never

B

Infrequently

C

Sometimes

D

At Least Daily

Question 18 of 47

Cheese

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 19 of 47

Eggs

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 20 of 47

Butter

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 21 of 47

Margarine

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 22 of 47

Yogurt

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 23 of 47

Aubergines (eggplant)

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 24 of 47

Oranges

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 25 of 47

Tomatoes

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 26 of 47

Potatoes

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 27 of 47

Cane sugar & cane beet products

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 28 of 47

Beetroot or beet sugar products

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 29 of 47

Breakfast cereals

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 30 of 47

Corn or corn products

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 31 of 47

Rice

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 32 of 47

Peanuts

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 33 of 47

Cakes or biscuits

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 34 of 47

Pasta or noodles

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 35 of 47

Soya

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 36 of 47

Saccharine

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 37 of 47

Chocolate

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 38 of 47

Fish

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 39 of 47

Chicken

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 40 of 47

Beef

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 41 of 47

Lamb

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 42 of 47

Preserved meat

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 43 of 47

Tea

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 44 of 47

Coffee

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 45 of 47

Canned drinks or squash

A

Never

B

Infrequently

C

Sometimes

D

Regularly

E

At least daily

Question 46 of 47

Check any of the following symptoms that you experience at present

(Select all that apply)
A

Red eyes

B

Runny / blocked nose, no cold

C

Bronchitis

D

Asthma

E

Giddiness

F

Ringing in the ears

G

Convulsions

H

Feeling faint

I

Feeling unwell all over

J

Tingling feeling after eating

K

Feeling of being poisoned

L

Nausea

M

Pain in stomach

N

Aching or swollen joints

O

Muscle cramp/ache

P

‘Dopey’ feeling

Q

Inability to think clearly

R

Irritability

S

Lack of confidence

T

Mood swings

U

Extreme moods

V

Itching

W

Eczema

X

Rash/spots/acne/mouth ulcers

Y

Puffy hands/face/abdomen

Z

Under/over/fluctuating weight

AA

Excessive sweating (not exercise-related)

AB

Unusually slow/rapid pulse

AC

Chest pain

AD

Palpitations after a meal

AE

Dyspepsia/flatulence; abdominal distress

AF

Diarrhea

AG

Constipation

AH

Variability of bowel function; frequent urination

AI

Menstrual problems

AJ

Panic attacks

AK

Lack of energy

AL

Persistent fatigue (not helped by rest)

Question 47 of 47

List any other symptoms or comments

Confirm and Submit