Allergy History
PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:
Digestive Track
nausea & vomiting
diarrhea
constipation
bloated feeling
stomach pains or cramps
heart burn
blood and/or mucous in stool
Ears
itchy ears
ear aches/ear infections
drainage from ear
ringing in ears
hearing loss
reddening of ears
Emotions
mood swings
anxiety/fear/nervousness
anger/irritability/aggressiveness
argumentative
frustrated/cries easily
Depression
Eyes
watery or itchy eyes
red/swollen/itchy eyelids
bags or dark circles under eyes
blurred or tunnel vision
Head
headaches
faintness
dizziness
insomnia/sleep disorder
facial flushing
Irregular/Skipped Heartbeat
Rapid/Pounding Heartbeat
Chest Pain
Joints & Muscles
pains/aches in joints
arthritis/osteoarthritis
stiffness/limited movement
pain/aches in muscles
feeling weak/tired
swollen/tender joints
growing pains in legs
Psoriatic/Gouty Arthritis
Rheumatoid Arthritis
Lungs
chest congestion
bronchitis
shortness of breath
difficulty breathing
persistent cough
wheezing
Mind
poor memory
difficulty completing projects
difficulty with mathematics
underachiever
poor/short attention span
confusion
easily distracted
difficulty making decisions
mild learning Disabilities
Mouth & Throat Thrush
chronic coughing
gagging/clearing throat often
sore throat/hoarse voice/voice loss
swollen/discolored tongue/lips
canker sores
itching on roof of mouth
Nose
stuffy nose
chronically red/inflamed nose
sinus problems
hay fever
sneezing attacks
excessive mucous formation
Skin
acne
itching
hives/rash/dry skin
hair loss
flushing/hot flashes
Weight
binge eating/drinking
craving certain foods
excessive weight
compulsive eating
water retention
General
frequent illness
frequent/urgent urination
genital itch/discharge
anal itching
Genitourinary
kidney problems
urinary tract
bladder
yeast infections
Other Conditions
Autism
A.D.H.D.
A.D.D.
Psoriasis
Eczema
Auto Immune Disorder
Chronic Fatigue
Multiple Chemical Sensitivities
Asthma
Congestive Heart Failure
Severe Diabetic
Severe Depression
Obsessive Compulsive Disorder
Patient Name
Date
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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