MCAS Screening Intake Form

MCAS Screening Intake Form
Please complete this intake form to help us assess Mast Cell Activation Syndrome (MCAS) symptoms and relevant history.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Have you been diagnosed with MCAS or any related mast cell disorder before?

Please indicate which of the following symptoms you have experienced in the past 6 months and rate their severity.

Please list any known triggers that worsen your symptoms (select all that apply):
Other
Please list all current medications (including supplements and over-the-counter):
Do you have any known allergies?
If yes, please specify your allergies:
Do you have a family history of MCAS or related conditions (e.g., allergies, asthma, autoimmune disorders)?
Please provide any other relevant medical history or comments:
Should be Empty:

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