AIM Food and Chemical Sensitivity Survey
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Please list all medications you are currently taking
 

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Please complete the following food and chemical sensitivity questionnaire. Score each symptom based upon your experiences over the last 60 days.  This survey should be taken again after the completion of the Alcat Test, prior to reintroduction of "reactive" foods.  Typically 3-6 months after initial testing. This comparison will help to assess the   success of the eating modification program. 
            
Symptom Scoring System
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Digestive Symptoms

 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Stomach Pains or Cramping  
Constipation  
Diarrhea  
Reflux or Heartburn  
Bloating  
Gas  
Nausea or Vomiting  
Weight
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Inability to Lose Weight  
Food Cravings  
Binge Eating  
Water Retention  
Sinus / Respiratory
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Stuffy or Runny Nose  
Asthma  
Chest Congestion  
Wheezing  
Frequent Sneezing  
Head / Ears 
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Migraines  
Headaches  
Earaches  
Ear Infection  
Ringing in Ears  
Eyes / Throat
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Itchy Eyes  
Watery Eyes  
Sore Thorat  
Persistent Canker Sores  
Emotional / Mental
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Depression  
Anxiety  
Mood Swings  
Irritability  
Poor Concentration  
Energy
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Fatigue  
Hyperactivity  
Lethargy  
Restleness  
Insomnia  
Skin Disorders
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Eczema  
Dermatitis  
Excessive Sweating  
Rashes  
Hives  
Other Symptoms
 No Symptoms (Zero Points) Experience Mild Symptoms (One Point) Experience Moderate Symptoms (Two Points) Severe Symptoms (Three Points)  
Joint Pain  
Arthritis  
Irregular Heartbeat  
Chest Pains  
Muscle Aches  

List any symptom not mentioned above:

 

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Total Score  (add up all your points)
 

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