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Immune Health Questionnaire
Immune Health Questionnaire
Name
Email address
Date
GENERAL ASSESSMENT:
How many hours do you sleep most nights?
<5
5-6
7-8
9+
How stressed do you usually feel on a scale of 0 to 10? (0 = least amount, 10 = highest amount)
0-2
3-5
6-7
8-10
How much time do you spend exercising? Please state how minutes per week and times per week
Are you a smoker?
Yes
No
How much alcohol (standard drinks) do you drink on weekdays?
How much alcohol do you drink on weekends?
Have you ever received a vaccine? If so, how often?
Never
Once or twice
Annually
Have you ever experienced an adverse reaction to the influenza vaccine or any other vaccination?
Yes
No
Please list any vaccination/s you have received and detail any adverse reactions:
How many serves of fruit and vegetables do you consume daily? (i.e. 1 serve = 1⁄2 cup)
0-3
4-6
7-8
9+
How many glasses of water do you drink per day? (i.e. 1 glass = 1 cup of water = 250 mL)
0-3
4-6
7-8
9+
TREATMENT PRIORITISATION:
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?
<1. (0 pts)
1-2. (1 pt)
3-4. (2 pts)
5+ (3 pts)
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)?
Yes (3 pts)
No (0 pts)
SECTION 1: On average, how many days does a cold or flu limit you from your regular activities, such as work or exercise?
<1 (0 pts)
1-2 (1 pt)
3-4 (2 pts)
5+ (3 pts)
TOTAL for SECTION 1:
SECTION 2: Do you struggle with lingering symptoms that persist following cold and flu recovery, such as nasal congestion or post nasal drip?
No (0 pts)
Yes (3 pts)
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)?
<1 (0 pts)
1-2 (1 pt)
3-4 (2 pts)
5+ (3 pts)
SECTION 2: Do you experience prolonged fatigue or struggle to ‘feel well’ in the weeks following a cold or flu?
No (0 pts)
Yes (3 pts)
TOTAL for SECTION 2:
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.)?
No (0 pts)
Yes (3 pts
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)?
No (0 pts)
Yes (3 pts
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.)?
No (0 pts)
Yes (3 pts
TOTAL for SECTION 3:
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)?
No (0 pts)
Yes (3 pts
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)?
Rarely (0 pts)
Once a month (1 pt)
Once a week (2 pts)
Daily
SECTION 4: How much do your allergies impact your daily life?
Rarely (0 pts)
Once a month (1 pt)
Once a week (2 pts)
Daily (3 pts)
TOTAL for SECTION 4:
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)?
No (0 pts)
Yes (3 pts
TOTAL for SECTION 5a:
SECTION 5b: How often do you use treatments to manage chronic inflammatory symptoms (i.e. joint pain, back pain, pain caused by past injuries)?
Rarely (0 pts)
Once a month (1 pt)
Once a week (2 pts)
Daily (3 pts)
SECTION 5b: How much do your symptoms impact your daily life?
None (0 pts)
A little (1 pt)
Moderate (2 pts)
Severe (3 pts)
TOTAL for SECTION 5b
SECTION 5c: Do you suffer from loss of cartilage that makes joint mobility painful?
No (0 pts)
Yes (3 pts)
SECTION 5c: Have you experienced a progressive worsening in pain symptoms (e.g. muscle, joint or nerve pain) over the last 12 months?
No (0 pts)
Yes (3 pts)
TOTAL for SECTION 5c:
SECTION 6: Have you followed a vegan or vegetarian diet over the last 12 months?
No (0 pts)
Yes (3 pts)
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)?
No (0 pts)
Yes (3 pts)
SECTION 6: Have you ever been diagnosed with coeliac disease or inflammatory bowel disease (IBD) or any condition that reduces nutrient absorption?
No (0 pts)
Yes (2 pts)
TOTAL for SECTION 6:
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
> 30 minutes (0 pts)
<15 minutes (1 pt)
<5 minutes (2 pts)
0 minutes (3 pts)
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
> 40 minutes (0 pts)
15-30 minutes (1 pt)
7-15 (2 pts)
<7 (3 pts)
SECTION 7: Do you have naturally dark brown skin (i.e. Fitzpatrick skin phototype V-VI)?
No (0 pts)
Yes (2 pts)
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?
No (0 pts)
Yes (3pts)
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)
No (0 pts)
Yes (3 pts)
* During summer, individuals with pale to moderate brown skin require 6 to 7 minutes of sun exposure (i.e. full arm exposure or equivalent area). In individuals with dark brown skin, 15 to 50 minutes is recommended. In winter, individuals with pale to moderate brown skin require between 7 to 40 minutes of sun exposure daily. In individuals with dark brown skin, it may not be possible to maintain vitamin D levels through sun exposure alone in southern states of Australia/New Zealand.
TOTAL for SECTION 7:
Submit
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