Immune System Function Questionnaire – Natural Health & Wellness Center

Are you susceptible to viruses and/or infections?*

Do you frequently have itchy eyes for nose?*

Do you have a chronic runny or stuffy nose?*

Do you frequently experience an itchy mouth or throat? *

Do you frequently have cold sores or fever blisters?*

Are you sensitive to chemicals?*

Do you have frequent skin rashes? *

Do you have reactions to certain foods?*

Do you experience fatigue not helped by rest? *

Do you feel you should eat a healthier diet?*

Are you lacking adequate sleep and relaxation? *

Do you live a stressful lifestyle? *

Name*

First Last

Phone*

Email*