EI Intake Questionnaire
Intake Questionnaire Part 2 - Environmental Illness (EI):
Symptoms, History, Exposures, Reactions, & Health assessment questions
The Counseling Center at CELA
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Initials (two letters only, one for first name / one for last name)
Describe how and when your environmental illness began
This information can include but is not limited to: specific EIs such as multiple chemical sensitivity, MCAS, mastocytosis, IBS, chronic fatigue; triggering event or events (such as exposure to pesticides, exposure to mold, exposure to toxic chemicals, or surgery); a chronology of symptoms and how they may have worsened over time
Does your current health significantly reduce your ability to do your job, housework, errands, chores, and/or other needed activities?
Not at all
Please describe the ways in which your life and activities of daily living are impacted and reduced due to your current health and current health issues
Are there any foods that you are sensitive to or that you experience reactions to after you eat them?
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