Van Family Chiropractic

Erin Van Veldhuizen, D.C., C.C.C.N.

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Online Allergy Form

Allergy Questionaire

Your Name(required)
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Please Check All That Apply To You

Digestive Track
nausea & vomiting diarrhea constipation bloated feeling stomach pains or cramps heart burn blood and/or mucous in stools
Ears
itchy ears ear aches/ear infections drainage from ear ringing in ears hearing loss reddening of ears
Emotions
mood swings anxiety/fear/nervousness anger/irritability/aggressiveness argumentative frustrated/cries easily Depression
Eyes
watery or itchy eyes red/swollen/itchy eyelids bags or dark circles under eyes blurred or tunnel vision
Head
headaches faintness dizziness insomnia/sleep disorder facial flushing Irregular/Skipped Heartbeat S Rapid/Pounding Heartbeat S Chest Pain S
Joints and Muscles
pains/aches in joints arthritis/osteoarthritis stiffness/limited movement pain/aches in muscles feeling weak/tired swollen/tender joints growing pains in legs
Lungs
chest congestion bronchitis shortness of breath difficulty breathing persistent cough wheezing
Mind
poor memory difficulty completing projects difficulty with mathematics underachiever poor/short attention span confusion easily distracted difficulty making decisions mild learning Disabilities
Mouth & Throat
chronic coughing gagging/clearing throat often sore throat/hoarse voice/voice loss swollen/discolored tongue/lips canker sores itching on roof of mouth
Nose
stuffy nose chronically red/inflamed nose sinus problems hay fever sneezing attacks excessive mucous formation
Skin
acne itching hives/rash/dry skin hair loss flushing/hot flashes
Weight
binge eating/drinking craving certain foods excessive weight compulsive eating water retention
General
frequent illness frequent/urgent urination genital itch/discharge anal itching
Genitourinary
kidney problems urinary tract bladder yeast infections
Other Conditions
Autism S A.D.H.D. S A.D.D. S Psoriasis S Eczema S Auto Immune Disorder S Chronic Fatigue S Multiple Chemical Sensitivities S Asthma S Congestive Heart Failure S Severe Diabetic S Severe Depression S Obsessive Compulsive Disorder
Please list your allergies of concern in order of importance:

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Dr. Erin Van Veldhuizen
Office Information

Location & Hours
4100 McEwen Rd.
Suite 130
Dallas, TX, 75244
Phone: (214) 295-9671
Email Dr. Erin
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Van Family Chiropractic

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