Foundation for Integrated Medicine Questionnaire
Mediators Questionnaire
Antecedents Questionnaire
Triggers Questionnaire
Effects Questionnaire
Reducing Questionnaire
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SECTION 1. Do you have food allergies?

My ears turn red for no apparent reason

My tongue looks like a map of Fantasyland,with irregular flattened patches

I have dark circles under my eyes
I have to clear my throat frequently
My lips or throat itch after eating
My skin itches for no apparent reason
The inner corners of my eyes itch
I feel sleepy after eating
I feel my best if I don't eat at all

I feel more hungry after eating than before I ate

I have irrestible cravings for specific foods (milk, for example)

Eating gives me diarrhea, headaches or skin rashes


If your total score is 5 or more, food allergy or food intolerance may be a trigger
for symptoms. See Appendix E of POWER HEALING. Food triggers are also likely
if you are troubled by any of the conditions listed in the Table of Appendix E.


SECTION 2. Are your intestines toxic?

My abdomen blows up like a balloon after eating
I have food allergies and they're increasing
I have diarrhea

I am constipated

My stomach feels best if I fast

My stomach feel best if I eat all the time

My stomach feel best when I take antibiotics

Antibiotics make me feel sick all over
I have mucus in my bowel movements
I have pain in my abdomen

I take anti-inflammatory drugs

I have more than two alcoholic drinks in a day
I travel to exotic places

    If your total score is 5 or more, you may have an intestinal toxicity syndrome.


SECTION 3. Is it mostly in your head?

It hurts when I chew
I have a foul taste in my mouth
My breath is offensive
My gums bleed
My face aches
I have a post-nasal drip
I have needed root canals
My teeth are in bad shape
I have had dental problems in the past
I have dental fillings

My energy improves when I take antibiotics


      If your total score is 7 or more, your teeth or your sinuses may harbor a
      trigger for illness. See your dentist or an ear, nose and throat specialist.


SECTION 4. Is it the air that you breathe?

At home, work or school I am exposed to —  
    Chemical fumes
    Solvents or cleaning materials
    Pesticides or herbicides
    Dampness, musty odors or mildew
    Computers, printers, office machines
    Glues or adhesives
    Construction materials

    Combustion engines or heater

    New fabric or carpeting
    Poor air quality that people complain about

        There's no need to total your score. A score of 2 or 3 in any category
        or a link between symptoms and any of these exposures is reason
        to clean up your environment.


SECTION 5. Is it the company of others?

I am subject to harassment at —  
I feel worse in the company of —  
    My spouse or partner
    My boss
    One or more of my co-workers
    One or more of my friends
    One or more of my relatives
I feel worse at gatherings or parties

    There is no need to total your score. A positive response to
    any question indicates that interpersonal or social distress may
    be a trigger for symptoms.

    Also ask yourself: Are there any thoughts, memories, smells
    or sounds that trigger (or relieve) my symptoms? If so, what are they?

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