EI Intake Questionnaire

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Intake Questionnaire Part 2 - Environmental Illness (EI):
Symptoms, History, Exposures, Reactions, & Health assessment questions
The Counseling Center at CELA

Email *

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? *

Severely

Moderately

Somewhat

A little

Not at all

Other:

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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