Allergies Survey

Sneezing, itching, a runny nose. These are just a few of the allergy symptoms you might be struggling with. Allergy symptoms don’t always have a clear cause but at Living Well Clinical Nutrition Center, we want to help you find relief. Complete this free quiz to see if you could benefit from our Living Well Program!

Please fill out this short survey (including your contact information) so that we can contact you further if needed. Your information will remain safe and confidential.

Rate each of the following based on your health in the last 90 days:

0 = Rarely or never experience the symptom
1 = Occasionally experience but effect is not severe
2 = Occasionally experience but effect is severe
3 = Frequently experience and effect is not severe
4 = Frequently experience and effect is severe

Watery, itchy eyes*
0 1 2 3 4
Runny nose*
0 1 2 3 4
Sneezing*
0 1 2 3 4
Itchy throat*
0 1 2 3 4
Itchy skin*
0 1 2 3 4
Post nasal drip*
0 1 2 3 4
Name*
First Last
Email*
Phone number*
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Allergies Survey

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