Name:___________________________________________    Date:_________________________

To be best of your recollection, when you were a child and now:
Did      (do) you....
Past       Now
____    ____ wet the bed? (age you stopped_______)
____    ____ have eczema or any other skin problem?
____    ____ have colic?
____    ____ have a feeding problem?
____    ____ have frequent ear problems?
____    ____ have croup?
____    ____ have frequent bronchitis or chest colds?
____    ____ have persistent (day or night) colds?
____    ____ have hay fever?
____    ____ have frequent attacks of "stomach ache," diarrhea, or vomiting?
____    ____ have circles under your eyes?
____    ____ have learning disabilities?
____    ____ have hyperactivity?
____    ____ have an inability to concentrate?
____    ____ have a stuffy nose?
____    ____ have growing pains?
____    ____ have asthma?
____    ____ have postnasal drip?
____    ____ have epilepsy?
____    ____ have facial
____    ____ have manic-depression?
____    ____ severe headaches, migraines
____    ____ have acute pain in the abdomen associated with headache, fatigue, dizziness, depression, hives or itching of the skin?
____    ____ have food allergies in the family?

FOOD:
Yes        No
____    ____ suspect any food of causing or aggravating your condition?
____    ____ go on eating binges or "food jags" where you crave milk, ice cream, yogurt, cheese, or 
                         doughy foods (pasta, bread, cookies, etc.) and eat them often?
____    ____ any foods you crave, love or overindulge in or eat frequently because you like them so 
                        much?    Please list:

____    ____ are there seasonal foods (i.e. strawberries, corn, tomatoes, peaches, etc) that you 
                         overindulge in?
____    ____ are there foods you find difficult to digest?    Please list:

____    ____ any foods you eat that cause nausea, vomiting, diarrhea, heartburn, belching, gas, 
                         cramps, hives, skin rashes, headache?
____    ____ chronic constipation and/or diarrhea?
____    ____ under eat or often prefer beverages to solid food?
____    ____ avoid food or throw up food because bloating after eating makes you feel fat or tired?
____    ____ can't gain weight?
____    ____ are you on any type of special diet at present?    Please list:

DIGESTION:
Yes         No
____    ____ Are you uncomfortable or ill if you do not eat on time?
____    ____ Do you have a sense of well-being after you eat?
____    ____ Are you more alert or energetic after eating?
____    ____ Do you feel better if you skip a meal or fast?
____    ____ Does fasting relieve any symptoms?
____    ____ Are you uncomfortable or sick when you fast?
____    ____ Do you feel good after a three to five day fast?

ALCOHOL:
Yes         No
____    ____ Do alcoholic beverages make you ill?
____    ____ Do alcoholic beverages take symptoms away?
____    ____ Do you get hangover symptoms from a single drink?

DIGESTION:
Yes        No
____    ____ Do you frequently belch or pass gas after meals?
____    ____ Do you often have indigestion and bloating or abdominal distention following meals?
____    ____ Is there any foods that you feel disagrees with you often or each time you eat it?
                            Please list:
____    ____ Do you often have attacks of diarrhea?
____    ____ Do you often have constipation or chronic constipation?
____    ____ Do you suffer with cramping pains in your abdomen?
____    ____ Have you been told you have spastic or mucous colitis?
____    ____ Have you ever been told you have gall bladder or bile duct disease?

EAR, NOSE, AND THROAT:
Yes         No
____    ____ Are you conscious of a foul odor in your nose?
____    ____ Do you have dripping from the back of your nose into your throat which has a  "sickening sweet" taste or is yellow or green?
____    ____ Have you ever been treated for "sinus trouble?"
____    ____ Do you have bad teeth?
____    ____ Do you have bad breath at times?
____    ____ Do your gums bleed?
____    ____ Do you have bad tonsils?
____    ____ Do your ears drain?

UROGENITAL:
Yes      No
____    ____ Do you have increased frequency of urination?
____    ____ Does urinating cause a burning sensation?
____    ____ As far as you know, do you have pus in your urine?
____    ____ Are you bothered with genital discharge?
____    ____ As far as you know, do you have an infection in any part of your body?
                            Please list:

WOMEN ONLY:
Yes      No
____    ____ Have you been told that you have a growth or erosion on your cervix that needs freezing or removal?

MEN ONLY:
Yes      No
____    ____ Have you been told that you have an infection of your prostate gland?
____    ____ Do you have low back pain?
____    ____ Do you have pains, at times, in your testicles?
____    ____ Do you have pain, at times, at the tip of your penis?
____    ____ Do you have trouble starting your stream when urinating?
____    ____ Do you have trouble getting an erection?
____    ____ Do you have trouble keeping an erection?

CONSIDER YOUR ALLERGIES OR SENSITIVITIES...WHAT MAKES YOU WORSE?
Are your troubles made worse or begin when.....
Yes        No
____    ____ you smoke?
____    ____ around others who smoke in small confined spaces?
____    ____ in nightclubs or other smoky places?
____    ____ in rooms with residual ash odors or on other person's clothing or breath?

Are your troubles made worse or begin when exposed.....
Yes         No
____    ____ to household insect powder or sprays
____    ____ to powders, sprays, or crystals used in moth proofing?
____    ____ to dusting powders, liquids or sprays used in the home or garden or on the lawn?
____    ____ to an environment after an exterminator has been there?

Are your troubles made worse or begin when.....
Yes         No
____    ____ the house is being cleaned or dusted?
____    ____ rugs are being beaten or
____    ____ the bed is made or the is turned?
____    ____ during spring house cleaning?
____    ____ the first cold snap of autumn comes and the heat is turned on?
____    ____ in theaters, churches, grocery stores, department stores, libraries, or bedroom where dust is noted?

Are your troubles made worse or begin when.....
Yes         No
____    ____ lying on a feather pillow?
____    ____ fluffing pillows?
____    ____ using a down comforter?
____    ____ near chickens, ducks, geese, pigeons, parrots, turkeys, canaries, or other birds?
____    ____ near someone who works around poultry or other birds?

Are your troubles made worse or begin when.....
Yes         No
____    ____ around any of the following animals (please circle): dogs, cats, horses, goats, sheep, rabbits, cows, pigs, domesticated furry animals?
____    ____ you handle or come into contact with any of the following (please circle): furs, rugs, certain articles of clothing, dress goods, blankets, gloves, hats, toy animals, brushes, carpets, other________________?
____    ____ you handle animal or poultry feeds?

Are your troubles made worse or begin when.....
Yes         No
____    ____ using scented face, talcum, body baths, or foot powders?
____    ____ in beauty salons or barber shops?
____    ____ around people who use a lot or powers, body lotions or perfumes?
____    ____ you use certain hair wave sets, shampoos, or tonics?

Are your troubles made worse or begin when.....
Yes         No
____    ____ there is a prolonged period of damp weather?
____    ____ you smell mildew?
____    ____ you are near hay or straw or when you go into an old damp musty house, a damp basement, a shed or cellar?
____    ____ you are near dry leaves or compost?

Yes         No
____    ____ Are you better in areas of the country when the snow is on the ground?
____    ____ Are you better at the beach in the summer?