The Centre for Natural Health

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Food Sensitivity Questionnaire


Modern day diets, prolonged antibiotic treatment, drugs, stress, busy lifestyle, all contribute to our becoming sensitive to certain foods, drinks and chemicals. By giving our bodies a rest from these we can help to heal ourselves.

Removing certain items of food and drink from our diet can bring improvements in our overall wellbeing, giving us increased energy and better weight control.

If you would like us to carry out a food sensitivity test for you this is what you need to do:

1. Complete and submit the form below

2. Follow the instructions on this page below the form regarding sending us your hair sample and payment


PLEASE NOTE: If you have any of the following symptoms or conditions, your own doctor should rule out potentially dangerous causes such as tumours or infections. If you have not already done so, please have your doctor conduct such an examination.


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Title:                            


First Name:                  


Surname:                     


Address:                      


Telephone no:              


Email address:              


Occupation:                  


Do you smoke?              


Do you drink alcohol?     



If you exhibit any of the following symptoms please check the box(es)


HEADACHE/MORNING MIGRAINE                                                                  TINNITUS/GIDDINESS

NASAL CATARRH                                                                                           MOUTH ULCERS/BAD BREATH

MENIER’S DISEASE                                                                                         RACING PULSE

HEAVY SWEATING (UNRELATED TO EXERCISE)                                            ASTHMA/HAYFEVER

ALLERGIC RHINITUS                                                                                      INDIGESTION/HEARTBURN

PEPTIC ULCER TYPE PAIN                                                                              BOWEL CRAMPS/COLIC

IRRITABLE BOWEL SYNDROME                                                                      SPASTIC COLITIS

DIARRHOEA AND/OR CONSTIPATION                                                          PILES (HAEMORRHOIDS)

FREQUENT URINATION:                                                                                CYSTITUS WITH/WITHOUT INFECTION

THRUSH                                                                                                          WATER RETENTION

FIBROSITIS/ACHING MUSCLES                                                                      ARTHRITIS/PAINFUL JOINTS

BACKACHE/SHOULDER PAINS                                                                       RHEUMATISM

ECZEMA/RASHES/HIVES                                                                                BLUSHING/ITCHING

ACNE WITH/WITHOUT INFLAMMATION                                                        LOSS OF APPETITE

PANIC ATTACKS/CHRONIC ANXIETY                                                             DEPRESSION/NERVOUS TENSION

HYPERACTIVITY/PURPOSELESS VIOLENCE                                                   FLEETING PAINS IN BREAST WITH/WITHOUT MASTITIS

MENSTRUAL DISORDERS                                                                               PRE-MENSTRUAL STRESS



Please indicate if any of these environments are relevant to you:


DOGS/CATS/HORSES                                                                                     RODENTS/HAMSTERS

COOKING - Gas                                                                                              COOKING - Electricity

COOKING - Microwave                                                                                   CALOR GAS

HEATING - Gas                                                                                               HEATING – Electricity

PAINTS/HOBBY WORK/GLUES                                                                        SPRAYS/AEROSOLS



Aside from any of the above symptoms or environments please include information about anything else you feel is important: drugs, supplements, washing powder, food/drink never consumed. Please specify in this box:



      

Once you have submitted this form please read the instructions below.

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WHAT NEXT?

Once you have submitted the above form please send us a small lock of your hair. This need only be enough to fill a teaspoon. Just sellotape the hair to a small piece of paper which has your name on it.
Send your hair sample to:

'Food Sensitivity Testing', The Centre for Natural Health, 14-16 The Broadway, Wickford, Essex SS11 7AA

HOW CAN I PAY?

Please enclose a cheque for £30 with your hair sample.
Make the cheque payable to: 'The Centre for Natural Health'

THE RESULTS

Once we have the results of your test we will email them to you. If you do not supply an email address we will post them to the name and address specified on the form.

If you submit a telephone number we will assume that you do not object to us calling you with a valid question.

If you would rather email us, contact our food sensitivity specialist direcly at fst@keepmewell.co.uk


Please be advised that any information you disclose will be held in the strictest confidence.

14-16 The Broadway, Wickford, Essex SS11 7AA - TEL: 01268 451663 | help@keepmewell.co.uk
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