| HISTAMINE INTOLERANCE QUESTIONNAIRE, eee Do YoU NOTICE ANY SYMPTOMS OR REACTIONS AFTER CONSUMING THE FOLLOWING Foops? Ds: Please circle Yes or No Instant Foods | ves [No ‘Nuts & Seasonings: All nuts, sunflower seeds, cinnamon, nutmeg, cloves, anise, curry powder Wes. [0 ‘Aditves & Preservative Tartrazne, Benzoates, Sulfites, BHA, BHT, MSG, nitrites, food colorings lee ‘Seatoo: Tuna, mackerel, sardines, anchovy, crustaceans, (eg. lobster, crab, shrimp), heting: preserved, marinated, yes | No salted or dred fish; rolled, pickled herring, fish sauces ‘Al raw, smoked-dred and pickled sausage; salami bacon, ham, sausage + Preserved meat of sausage + Packaged meats / poultry that has nat been properly re-sealed after use ves. No + Minced or shredded meats unless they are very fresh + Re-heated prepared dishes containing meat or poultry Eas (cheeses with a long maturation period; hard cheeses like Emmentaler, Bergkase, Parmesan, + Mature o overtipe pieces of sot cheeses and bleu cheese, ricotta * Cheeses fram raw milk Yes | ow Milk, youur, ket, cream, buttermilk Bread, Cereals & Confections: Yeast is very high i histamine + Baking powder and other chemical leavening agents are high in histamine * Avoid all brea, ols, pastries made prepared with leavening agers. eee {Buckwheat Vegetables & Legumes: Avocado, eggplant, mushrooms, pumpkin, spinach + Tomatoes and tomato products + Soy and soy products, especially fermented YES. No “Red beans + Pickles, olives, sauerkraut and any vegetable marinated in a vinegar-based marinade ARE YOU TAKING ANY OF THE FOLLOWING DRUGS? Acetyl Cysteine Ambrowole (mucolytie medication) ‘Aminophylline (broncholytic) Amilryptyline (antidepressant Cefuroxime, cefotiam, isoniazid, pentamidin, clavulanie aed, choroguine (antibiotics) Cimetidine (H2 antagonist) Contrast media (Cyclophosphamide (eytostatic) Dobutarnine fantinypotonic) NSAIDs, (buprofin , Aspirin, Naproren ASA, morphine, penthedine, metamizole (analgesics) ‘Metoclopramide (gut motility) Pancuronium, alcuronium, D-tubocurarine (musts relaxants) Propafenone (antiartiythymic) Prilocaine (local anaesthesia) Verapamil alprenoll, cihydralazine (antihypertensives) “Thiopental (narcotic) £05 J! x09 aU} AUD 8S0iq PATIENT NAME: Date:HISTAMINE INTOLERANCE QUESTIONNAIRE PLEASE RATE THE SEVERITY OF THE FOLLOWING CONDITIONS AND SYMPTOMS: AA) None BB) Seldom (less than once a day) ©) Often (daily) D) Very often (hourly) Please circle the appropriate rating: ‘Rodominal Pain, Spasms a 8 c D Flatulence (Gas) a 8 c D Diarhea a 8 c D Flushing or reddening of the skin (rosa0ea of the face) a 8 c D itehing a 8 c D Headache, including migraine and menstrual migraine 7B 8 c D Fatigue a 8 c D Rheumatic changes (loint discomfort) a 8 c D Nausea a 8 c D Dizziness a 8 c D Chron constipation A 8 c D Skin cash (may be chon or sporadi, unknown cause) A 8 c D Panic attacks, sudden changes in psychi states (e.. aggression, dificully concentrating, | A e c D 00" attention) usually during or ater @ mel. “Leaden exhaustion” usually during or ater a meal, often requiring sieep;however, sleep a 8 c D oes not restore vitality Chil, shivers, discomfort, low blood pressure a @ c D Shortness of breath A 8 ¢ D Do YOU NOTICE ANY SYMPTOMS OR REACTIONS AFTER CONSUMING THE FOLLOWING Foops? ae Beverages: All aleohalic beverages, including beer, ale, wine and distilled alcohol, All special “de-aleoholized” beverages ves | No such as beer, wine, chocolate, cocoa and cola drinks, tea (green, reguar, herbal) Pizza ves | No Chocolate ves | NO Fruits: + Orange, grapefruit, lemon, lime + Apricots, plums, cheries * Cranberries + Brunes, dates, raisins, curants, died cranberries Mo | «Pineapple, papaya, mango = Strawberries, raspberries, loganberries, cranberries