Immune Health Questionnaire



Immune Health Questionnaire
How many hours do you sleep most nights?
How stressed do you usually feel on a scale of 0 to 10? (0 = least amount, 10 = highest amount)
Are you a smoker?
Have you ever received a vaccine? If so, how often?
Have you ever experienced an adverse reaction to the influenza vaccine or any other vaccination?
How many serves of fruit and vegetables do you consume daily? (i.e. 1 serve = 1⁄2 cup)
How many glasses of water do you drink per day? (i.e. 1 glass = 1 cup of water = 250 mL)
SECTION 1: How often have you experienced cold and flu symptoms (e.g. fever, sore throat, runny nose, coughing and/or lethargy) in the last 12 months?
SECTION 1: Do you feel like you catch a cold or the flu more frequently than people around you (e.g. family members or co-workers)?
SECTION 1: On average, how many days does a cold or flu limit you from your regular activities, such as work or exercise?
SECTION 2: Do you struggle with lingering symptoms that persist following cold and flu recovery, such as nasal congestion or post nasal drip?
SECTION 2: In the last year, how often have you experienced recurring episodes of the same infection/symptoms of relapsing infections (i.e. sinusitis, tonsilitis, bronchitis, cold sores or skin infections e.g. Staphylococcus)?
SECTION 2: Do you experience prolonged fatigue or struggle to ‘feel well’ in the weeks following a cold or flu?
SECTION 3: Do you have a history of chronic infections (e.g. Epstein-Barr virus, shingles, hepatitis, tick-borne infections, sexually transmitted infections [STIs] etc.)?
SECTION 3: Have you ever experienced persistent fatigue for longer than 3 months following an infection? Do you experience ongoing relapses of chronic fatigue syndrome (CFS)?
SECTION 3: Are you considered to be immunosuppressed (i.e. diagnosed with immune deficiency illness or autoimmune disease), or have you received immunosuppressive treatments in the last two years (i.e. treatments for organ transplant, corticosteroids treatments, chemotherapy etc.)?
SECTION 4: Do you experience allergy symptoms (e.g. itchy skin or eyes, swelling, or asthmatic cough) that worsen seasonally or when you are exposed to animal dander, pollen or particular foods (i.e. wheat, dairy, soy or nuts)?
SECTION 4: How often do you use treatments such as steroid creams, antihistamines or steroid inhalers to manage allergy symptoms (i.e. eczema, hay fever or asthma)?
SECTION 4: How much do your allergies impact your daily life?
SECTION 5a: Have you been diagnosed with a chronic inflammatory or autoimmune disease that is difficult to manage (i.e. difficult to control symptom flares or maintain remission from pain)?
SECTION 5b: How often do you use treatments to manage chronic inflammatory symptoms (i.e. joint pain, back pain, pain caused by past injuries)?
SECTION 5b: How much do your symptoms impact your daily life?
SECTION 5c: Do you suffer from loss of cartilage that makes joint mobility painful?
SECTION 5c: Have you experienced a progressive worsening in pain symptoms (e.g. muscle, joint or nerve pain) over the last 12 months?
SECTION 6: Have you followed a vegan or vegetarian diet over the last 12 months?
SECTION 6: In the last six months, have you taken prescribed medicines such as the oral contraceptive pill, antacids (reflux medication), diuretics, or have required the ongoing use of non-steroidal anti-inflammatories (NSAIDs)?
SECTION 6: Have you ever been diagnosed with coeliac disease or inflammatory bowel disease (IBD) or any condition that reduces nutrient absorption?
SECTION 7: From spring to autumn, how much time per day do you spend in direct sunlight with arms exposed between 10 am and 2 pm? *Please tick one answer depending on current season. Spring -Autumn
SECTION 7: In winter, how much time per day do you spend in direct sunlight with arms exposed between 10 am and 2 pm? *Please tick one answer depending on current season. Winter
SECTION 7: Do you have naturally dark brown skin (i.e. Fitzpatrick skin phototype V-VI)?
SECTION 7: Do you live in a southern region below a latitude of 35° (i.e. Canberra, Adelaide, Melbourne, Hobart or New Zealand) during the winter months of the year?
SECTION 7: In the last three months, have you had your vitamin D levels assessed and determined to be insufficient (i.e. <40-50 nmol/L)? (Leave blank if unsure)