The Food Intolerance Questionnaire

SECTION ONE - DIGESTIVE SYMPTOMS

• Abdominal bloating / distention (2)
• Abdominal cramps (2)
• Abdominal or stomach pain (2)
• Burping after eating certain foods 
• Catarrh (mucus) (2)
• Difficulty losing weight 
• Difficulty gaining weight 
• Enuresis (bed wetting) (2)
• Excess wind (flatulence) 
• Gallbladder problems (difficulty digesting fats)
• Gastro-Oesophageal Reflux Disease (GORD) (2)
• Glue Ear (Otitis Media) (2)
• Gritty feeling in the eyes (2)
• Haemorrhoids (piles) (2)
• Indigestion (recurring) (2)
• Inexplicable weight gain or weight loss
• Irregular bowel motions (eg constipation or diarrhoea) (2)
• Irritable Bowel Syndrome (IBS) (2)
• Itchy bottom 
• Itchy, red ears (2)
• Metallic taste in the mouth (2)
• Mouth ulcers (2)
• Nausea
• Persistent need to clear your throat / sore throat (2)
• Post-nasal drip (2)
• Rhinitis (runny nose) (2)
• Sinusitis (2)
• Sneezing - frequent (2)
• Water retention
  
  (20 x 2 = 40)
  (9 x 1 = 9)
  Sub-total/ maximum =    /49

SECTION TWO - MENTAL, EMOTIONAL AND NERVOUS SYSTEM SYMPTOMS

• Addictions
• Aggressive outbursts
• Attention Deficit Disorder / ADHD (2)
• Anxiety 
• Behavioural Problems (2)
• Blankness or momentary difficulty in finding the right word/s (2)
• Blurred vision (2)
• Brain fag (2)
• Changes in handwriting (2)
• Clumsiness (2)
• Confusion 
• Constant hunger (2)
• Dark circles under your eyes (2)
• Depression
• Dilated blood vessels in your cheeks and nose (2)
• Dizziness
• Dyslexia (2)
• Fidgetting
• Foggy head (2)
• Food cravings (2)
• Headaches
• Hyperactivity (esp. in children) (2)
• Inability to think clearly (2)
• Insomnia
• Irritability
• Lack of motivation / get up and go
• Migraines (2)
• Mood swings
• Palpitations
• Panic attacks
• Phobias
• Poor concentration
• Racing pulse
• Restless legs syndrome
• Slurred speech
• Spacey (2)
• Tenseness
• Tinnitus (ringing in the ears) (2)
• Uncharacteristic inability to make decisions
  
  (18 x 2 = 36)
  (21 x 1 = 21)
  Sub-total /maximum =   /57

SECTION THREE - OVERT PHYSICAL SIGNS AND SYMPTOMS