Food Intolerance

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Questionnaires - Food Intolerance
If you regularly have any of the 80 plus symptoms on the Food Intolerance Questionnaire, this could be a sign that you have food intolerances, particularly if you know of no other reason why your symptoms might be present. This questionnaire can be printed out for completion. Please refer to the book 'The Food Intolerance Bible' for your interpretation and Action Plan. A copy may be purchased on this website if you do not already have one.
 
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Food IntoleranceFood Intolerance
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The Food Intolerance Questionnaire
The Food Intolerance Questionnaire
Do you suffer on a regular basis (i.e. more than 3 times a week) from any of the following?

 

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

  • Abnormal physical weakness or tiredness
  • Aching muscles and joints for no good reason (2)
  • Arthritis
  • Asthma
  • Chronic Infections
  • Eczema
  • Fibromyalgia (diagnosed by a physical therapist or doctor) (2)
  • Hives (urticaria) (2)
  • Itching (2)
  • Painful joints in which the pain moves from one joint to another (2)
  • Painful joint that is not associated with excessive use (2)
  • Psoriasis (2)
  • Rheumatoid Arthritis
  • Rough dry skin
  • Spots or acne (that is not hormonally related)
  • Skin rashes (for no other known reason) (2)
  • Wheezing

    (8 x 2 = 16)
    (9 x 1 = 9)
    Sub-total /maximum =    /25

 

WHAT IS YOUR SCORE?

Section One            /49
Section Two           /57
Section Three        /25

Overall Total         /131

 
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 Questionnaires > Food Intolerance

See also:
Low Stomach Acid
Digestive Enzymes
Yeast Related Illness
Parasites
Stress Related
Leaky Gut

           

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