| Questions |
Yes |
No |
| Have
you taken repeated or prolonged courses of antibacterial
drugs? |
|
|
| Have
you been bothered by recurrent vaginal, prostate or
urinary tract infections? |
|
|
| Do
you feel "sick all over," yet the cause hasn't
been found? |
|
|
| Are
you bothered by hormone disturbances, including PMS,
menstrual irregularities, sexual dysfunction, sugar
craving, low body temperature or fatigue? |
|
|
| Are
you unusually sensitive to tobacco smoke, perfumes,
colognes and other chemical odors? |
|
|
| Are
you bothered by memory or concentration problems? Do
you sometimes feel "spaced out"? |
|
|
| Have
you taken prolonged courses of prednisone or other steroids;
or have you taken "the pill" for more than
3 years? |
|
|
| Do
some foods disagree with you or trigger your symptoms? |
|
|
| Do
you suffer with constipation, diarrhea, bloating or
abdominal pain? |
|
|
| Does
your skin itch, tingle or burn; or is it unusually dry;
or are you bothered by rashes? |
|
|
