Food/Chemical Intolerance Survey (A)

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Date
(enter as day / month / year)
Section A: Familial Associations
1. Do you or other member(s) of your household have an intolerance? (Y or N)
2.
 Please answer if more than one member of your household has an intolerance.
Number of persons in your household with an intolerance:
What is biological relationship of those persons? (enter the number of persons)
Siblings Parent/Child Grandparent/Child None
Other (please specify)
3. Are you aware of other members of your family, not living in your household
who have an intolerance? (only biologically related family members) (Y or N)
If yes, what is biological relationship of those persons? (enter the number of persons)
Siblings Parent/Child Grandparent/Child
Other (please specify)
Section B: Details of Intolerance
1. Identify the intolerances in your household. (specify the number of persons with each
intolerance by writing the number in the corresponding box):
Amines (any) Nitrates/Nitrites
Antioxidants Salicylates (any)
Aspartamine Sorbates
Benzoates Soy Products
Gluten Sulfates/Sulphates
Lactose Sulfites/Sulphites
MSG Yeast
Other (please specify)
2. Identify the symptoms currently or at any time experienced by members of your household
believed to be related to intolerance. (enter the number of persons)
Anxiety/Panic Attacks Joint Aches/Pain
Back Pain Lack of confidence
Bloating (not menstrual) Loss of concentration
Candida Memory Loss
Constipation Motion/Air Sickness
Depression Muscle Aches/Pain
Diarrhea Nausea
Facial Blemishes Rashes and/or Hives
Fatigue Reflux
Fever or Chills Shakes
Finger/Toe Nail Distortion Swollen Nasal Passages
Fluid Retention Swollen/Sore Throat
Hair Loss/Thinning Swollen Tongue
Headaches/Migraines Vomiting
Intestinal Cramp/Pain
Other (please specify)
Section C: Diagnosis
1. Indicate the number of persons in your household diagnosed by the following:
doctor (general practitioner) naturopath homeopath
immunologist/allergist self-diagnosis other (please specify)
2.
 From the time each member of your household recognized the first symptoms how long was it
before a correct diagnosis of the sensitivity/intolerance was established? (enter the number of
persons)
less than 1 month 1-2 months 2-3 months 3-4 months
4-5 months 5-6 months 6 months - 1 year 1-2 years
2-3 years 3-5 years 5-10 years more than 10 years
3.
 Please answer for each member of your household even if some or all were self-diagnosed.
How many medical/health practitioners/professionals did each member of your household consult
about symptoms/illness before each one was correctly diagnosed? (enter the number of persons)
0 1 2 3 4 5 more than 5
4.
 Which medical/health practitioners/professionals have been of most assistance to you and your
household since your diagnosis? (enter number of persons in your household)
doctor (general practitioner) naturopath homeopath
immunologist/allergist dietitian
other, please specify
None of the members of my household have consulted any medical/health
practitioners/professionals concerning sensitivity/intolerance since diagnosis. (if yes, X)
5.
 If you or any members of your household were self-diagnosed, what information led you to the
diagnosis? (Fill in as many as are applicable.)
a.
 information from a friend (if yes, X)
b.
 a book, please give details if you can
c.
 a magazine article, please give details if you can
d.
 information found on the Internet, please give details if you can, e.g. site address
e.
 trial and error (if yes, X)
f.
 food diary (if yes, X)
g.
 other (please specify)
6.
 In what year(s) were you and other members of your household diagnosed?
Section D: Consequences
Please answer this section by entering the number of persons in your household who have suffered these consequences.
1.
 As a result of your symptoms have you
a.
 had to significantly alter your lifestyle? Yes No
If yes,
do you consider the changes you have made a positive or
a negative consequence
b.
 been fired/sacked from any place of employment (paid or unpaid)?
c.
 had to rely on family, friends or paid assistance to accomplish daily tasks, e.g. shopping,
house cleaning, gardening etc.
d.
 had less contact with family and friends?
e.
 become depressed?
Section E: Geographic
Please answer on behalf of each person in your household who has a chemical sensitivity/intolerance. Space is provided for 4 persons. If you have more than 4 chemically intolerant persons in your household, please send a second form with only the date and Section E filled out.

NB. Additional Comments may be added in the box at the end of this form.
Person 1:
Your intolerance(s):
Country of birth:
Country of mother's birth:
Country of maternal grandmother's birth:
Country of maternal grandfather's birth:
Country of father's birth:
Country of paternal grandmother's birth:
Country of paternal grandfather's birth:
If any of your great-grandparents were born in a country that was not mentioned above, please,
state which country/countries.
Country in which you currently reside:
City/Town/Village in which you currently reside (include state/region/province if applicable):
How long have you lived in this area? years months
In what year did you move to this area?
Age:
Name (optional):
Email Address (optional):
(Your name and email address will be treated as confidential. They will only be used in the case of any follow up questions and will not be made available to persons other than the researcher.)
Thank you for your participation.
Person 2:
Person 2's intolerance(s):
Country of birth:
Country of mother's birth:
Country of maternal grandmother's birth:
Country of maternal grandfather's birth:
Country of father's birth:
Country of paternal grandmother's birth:
Country of paternal grandfather's birth:
If any of your great-grandparents were born in a country that was not mentioned above, please,
state which country/countries.
Country in which you currently reside:
City/Town/Village in which you currently reside (include state/region/province if applicable):
How long have you lived in this area? years months
In what year did you move to this area?
Age:
Name (optional):
Email Address (optional):
(Your name and email address will be treated as confidential. They will only be used in the case of any follow up questions and will not be made available to persons other than the researcher.)
Thank you for your participation.
Person 3:
Person 3's intolerance(s):
Country of birth:
Country of mother's birth:
Country of maternal grandmother's birth:
Country of maternal grandfather's birth:
Country of father's birth:
Country of paternal grandmother's birth:
Country of paternal grandfather's birth:
If any of your great-grandparents were born in a country that was not mentioned above, please,
state which country/countries.
Country in which you currently reside:
City/Town/Village in which you currently reside (include state/region/province if applicable):
How long have you lived in this area? years months
In what year did you move to this area?
Age:
Name (optional):
Email Address (optional):
(Your name and email address will be treated as confidential. They will only be used in the case of any follow up questions and will not be made available to persons other than the researcher.)
Thank you for your participation.
Person 4:
Person 4's intolerance(s):
Country of birth:
Country of mother's birth:
Country of maternal grandmother's birth:
Country of maternal grandfather's birth:
Country of father's birth:
Country of paternal grandmother's birth:
Country of paternal grandfather's birth:
If any of your great-grandparents were born in a country that was not mentioned above, please,
state which country/countries.
Country in which you currently reside:
City/Town/Village in which you currently reside (include state/region/province if applicable):
How long have you lived in this area? years months
In what year did you move to this area?
Age:
Name (optional):
Email Address (optional):
(Your name and email address will be treated as confidential. They will only be used in the case of any follow up questions and will not be made available to persons other than the researcher.)
Thank you for your participation.
Additional Comments: