This subjective questionnaire will give your health care practitioner a quick summary of symptoms or signs that may be related to immune system function. It is not a substitute for professional medical advice from your health care provider. Are you susceptible to viruses and/or infections?*YesNoDo you frequently have itchy eyes for nose?*YesNoDo you have a chronic runny or stuffy nose?*YesNoDo you frequently experience an itchy mouth or throat? *YesNoDo you frequently have cold sores or fever blisters?*YesNoAre you sensitive to chemicals?*YesNoDo you have frequent skin rashes? *YesNoDo you have reactions to certain foods?*YesNoDo you experience fatigue not helped by rest? *YesNoDo you feel you should eat a healthier diet?*YesNoAre you lacking adequate sleep and relaxation? *YesNoDo you live a stressful lifestyle? *YesNoName* First Last Phone*Email*