Ask Yourself...

This questionnaire is designed to help determine if some of your symptoms are related to disturbed body functions. Please read each question carefully. Then circle "Yes" or "No" to indicate your answer.

YES NO 1. Are there any foods that you crave or eat frequently?

YES NO 2. Are there foods that you dislike?

YES NO 3. Do you find that your clothing becomes too tight as the day goes on - even if you haven't overeaten?

YES NO 4. Did any member of your family have hayfever, asthma, hives, chronic skin condition, migraine headaches, or colitis?

YES NO 5. During childhood, did you have any of the following: colic, eczema, hayfever, asthma, or food feeding problem?

YES NO 6. Do you ever have itching of the skin, palate, or roof of mouth?

YES NO 7. Are you frequently hungry soon after a meal, even if you ate a sufficient amount?

YES NO 8. Do you have marked fatigue 2 or 3 hours after meals?

YES NO 9. Do you eat snacks frequently between meals?

YES NO 10. Are you addicted to any foods?

YES NO 11. Is there any food you find impossible to live without?

YES NO 12. Do you experience belching, abdominal distension, bloating or cramps following meals?

YES NO 13. Do you experience episodes of "spaciness" or the inability to concentrate?

YES NO 14. Do you have drowsiness, headache, or bloating following the ingestion of a glass of beer or wine?