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Immune System Function Questionnaire

Fill out the form below and click "Submit"
to send us your information for evaluation.

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Name*:

Email*:

Are you susceptible to viruses and/or infections?*:

Yes No

Do you frequently have itchy eyes or nose?*:

Yes No

Do you have a chronic runny or stuffy nose?*:

Yes No

Do you frequently experience an itchy mouth or throat?*:

Yes No

Do you frequently have cold sores or fever blisters?*:

Yes No

Are you sensitive to chemicals?*:

Yes No

Do you have frequent skin rashes?*:

Yes No

Do you have reactions to certain foods?*:

Yes No

Do you experience fatigue not helped by rest?*:

Yes No

Do you feel you should eat a healthier diet?*:

Yes No

Are you lacking adequate sleep and relaxation?*:

Yes No

Do you live a stressful lifestyle?*:

Yes No

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