Free Distant NAET Allergy Healing Questionnaire

Health Questionnaire

Allergy Elimination Clinic

1596 Nipa Blvd.

Fairfield, IA 52556

Phone 641-209-1778

Please take some time to complete and email this health questionnaire. The simplest way to handle this form is to cut and paste it into your email. It will expand to contain all information as you fill it out. If you are concerned with email confidentiality, you may either fax or mail this completed form.

Please answer all questions.

Name

Address

Phone

Email

Age

Occupation

Marital status

# of children

To what foods do you think you are allergic?

To what environmental items do you think you are allergic?

Describe your most severe allergic reaction.

Do you have immediate family members who are allergic?

When did your allergies first begin?

Was there some stressful or traumatic event that occurred about the time your allergies began? (accident, divorce, severe illness, etc)

List any prescription medications.

List any dietary supplements

Do you have seasonal allergies?

If you have had NAET treatments before, please answer the following seven questions:

1. Did you pass your treatments easily?

2. Did you have to repeat many treatments?

3. Are you no longer allergic to the items for which you were treated?

4. Did you require many combination treatments?

5. Did you require many emotional treatments?

6.Were you uncomfortable during the period when the meridians were clearing (2-24

hours after treatment)?

7. List as many items as you can for which you were treated.

Are your allergies more severe at different times of the day? When?

Describe your physical allergic symptoms

Describe the way you feel emotionally when you have a flare up of allergic symptoms.

When was the last time you had a complete physical examination?

Do you feel better or worse at work?

Do you feel better when you travel?

List any past and present serious health problems other than allergies

List any accidents and hospitalizations

How is your energy level?

How acute is your mental functioning? (concentration, comprehension, memory)

Are you able to exercise? How much?

Do you smoke, drink alcohol, drink coffee, use recreational drugs?

Are there any further comments that you would like to add?

Remember to return this completed form after you have finished.



	Health Questionnaire Allergy Elimination Clinic 1596 Nipa Blvd. Fairfield, IA 52556 Phone 641-209-1778 Email: allerdoc@lisco.com Please take some time to complete and email this health questionnaire. The simplest way to handle this form is to cut and paste it into your email. It will expand to contain all information as you fill it out. If you are concerned with email confidentiality, you may either fax or mail this completed form. Please answer all questions. Name Address Phone Email Age Occupation Marital status # of children To what foods do you think you are allergic? To what environmental items do you think you are allergic? Describe your most severe allergic reaction. Do you have immediate family members who are allergic? When did your allergies first begin? Was there some stressful or traumatic event that occurred about the time your allergies began? (accident, divorce, severe illness, etc) List any prescription medications. List any dietary supplements Do you have seasonal allergies? If you have had NAET treatments before, please answer the following seven questions: 1. Did you pass your treatments easily? 2. Did you have to repeat many treatments? 3. Are you no longer allergic to the items for which you were treated? 4. Did you require many combination treatments? 5. Did you require many emotional treatments? 6.Were you uncomfortable during the period when the meridians were clearing (2-24 hours after treatment)? 7. List as many items as you can for which you were treated. Are your allergies more severe at different times of the day? When? Describe your physical allergic symptoms Describe the way you feel emotionally when you have a flare up of allergic symptoms. When was the last time you had a complete physical examination? Do you feel better or worse at work? Do you feel better when you travel? List any past and present serious health problems other than allergies List any accidents and hospitalizations How is your energy level? How acute is your mental functioning? (concentration, comprehension, memory) Are you able to exercise? How much? Do you smoke, drink alcohol, drink coffee, use recreational drugs? Are there any further comments that you would like to add? Remember to return this completed form after you have finished.