Mast Cell Activation Syndrome (MCAS) Clinical Questionnaire

Full Name

Email Address

Age

Date

Please tick the relevant checkbox if you have the following symptoms and traits:

General: Symptoms and Traits

“I have been sick for as long as I can remember’

Abdominal pain as an infant

Decreased wound healing

Early satiety

Edema – “water” accumulation in different parts of the body

Food, drug, and chemical intolerances (especially fragrances)

Frequent family history of cancer especially intestinal or bone marrow (hematologic)

Frequent fatigue and malaise or Chronic Fatigue Syndrome

Frequent fevers and/or sweats

Frequent infections, cold, viruses, gut viruses as an infant, adolescent or adult

General feeling inflamed

Generalized lymphadenopathy (enlarged lymph nodes)

Heat intolerance

Hypersensitivity to much in environment including fragrances, perfumes, or medications

Insomnia

Sense of being cold all the time

Vomiting as an infant

Waxing and waning of symptoms

Weight gain or loss

Weight gain or loss – can go up and down

Ears - Symptoms and Traits

Ringing in ears (tinnitus)

Eustachian tube dysfunction (blocked, popping ears)

Hearing loss

Otosclerosis

New Option

Eyes - Symptoms and Traits

Burning eyes

Conjunctivitis

Difficulty focusing

Difficulty focusing vision

Dry eyes

Increased or decreased tearing

Irritated eyes

Red eyes

Sun sensitivity

Tic or eyelid spasm

Nose - Symptoms and Traits

Hoarseness

Intranasal sores

Laryngitis

Nasal stuffiness

Nose bleeds (epistaxis)

Post nasal drip

Rhinitis

Sinusitis

Throat- Symptoms and Traits

Burning mouth

Difficulty swallowing

Itchy throat

Sores on tongue/mouth

Throat swelling

Vocal cord dysfunction

Throat tickle

Skin - Symptoms and Traits

Angioedema

Brittle nails

Cannot heal when cut

Cherry angiomata/ red spots

Chronic itching

Dermatographism (scratch the skin – red welt arises)

Easy bruising

Eczema

Fungal skin infections

Hair thinning or alopecia

Hives

Itchiness

Lichen planus

Patchy red rashes

Red face when waken

Reddish or pale complexion

Skin flushing

Skin rashes

Skin tags

Urticarial pigmentosa

Warts

Cardiovascular - Symptoms and Traits

Abnormal heart rythm

Dizzy

Edema

Fainting

Fainting upon standing

High triglycerides

Hot flushes

Light headedness

Palpitations

Increased pulse rate (tachycardia)

POTS syndrome

Spikes and drops in blood pressure, pulse or temperature

Respiratory- Symptoms and Traits *

Air hunger

Asthma

Can’t catch a deep breath

Chronic interstitial fibrosis

COPD

Dry cough

Pulmonary hypertension

Shortness of breath

Wheezing

GI- Symptoms and Traits

Abdominal cramping and bloating

Colonic polyps

Cyclic vomiting syndrome

Diarrhea and/or constipation

Difficulty swallowing

Epigastric tenderness

IBS

Gastric polyps

GERD/acid reflux – refractory to medication

Left upper abdominal pain

Malabsorption

Nausea

Non-cardiac chest pain

Splenomegaly (enlarged spleen)

Vomiting

Liver- Symptoms and Traits

Elevated liver enzymes

High bilirubin

High cholesterol

Neurological- Symptoms and Traits

Headaches

Memory loss

Migraines

Numbness and tingling, especially hands and feet

Poor concentration

Pseudo seizures

Sleep disorders

Spells of cataplexy (suddenly becoming disconnected from and unresponsive to the world around)

Tics or tremors

True seizures

Waxing and waning brain fog

Word finding difficulty

Musculoskeletal- Symptoms and Traits

Ehler’s Danlos Syndrome

Fibromyalgia

Hypermobility

Increased osteopenia and osteoporosis

Joint laxity

Migratory arthritis (joint pain)

Muscle pain

Myositis

Weakness

Coagulation- Symptoms and Traits

Bleeding nose

Deep vein thrombosis

Don’t clot when cut

Heavy menstrual bleeding

History of clots

Increased bruising

Blood Disorders- Symptoms and Traits

Abnormal electrolytes

Anemia

Autoimmune markers

Decreased lymphocytes

Decreased neutrophils

Decreased platelets

Decreased white cell count

High IgE

Increased MCV (mean corpuscular volume)

Increased white cell count

Monoclonal gammopathy

Reductions in CD4 helper lymphocytes

Reductions in CD8 positive suppressor lymphocytes

Reductions or excesses of IgA, IgG, IgM, IgE

Psychiatry- Symptoms and Traits

Anxiety

Bipolar disorder

Decreased attention (ADD) / ADHD

Depression

Forgetful

Insomnia

OCD

Panic

PTSD -Post Traumatic Stress Disorder

Genitourinary- Symptoms and Traits

Frequent urination

Interstitial cystitis

Recurrent bladder infections

Sterile bladder infections

Vaginitis

Hormones- Symptoms and Traits

Decreased libido

Decreased sperm counts

Endometriosis

Erectile dysfunction

Heavy periods

Infertility

Painful periods

Recurrent miscarriages

Dental- Symptoms and Traits

Deteriorating teeth

Anaphylaxis- Symptoms and Traits

Diarrhea

Difficulty breathing

Dizziness and fainting

Feeling of warmth

Flushing or pale skin

Itchy hives

Nausea

Vomiting

Common triggers include- Symptoms and Traits

Airborne smells including perfumes or smoke

Anesthetic

Emotional stress

Exercise or exertion

Procaine and dental anesthetic

Specific foods and drinks (especially alcohol and high-histamine content foods)

Temperature extreme

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