Food Sensitivity Qualification

To see if you qualify for Dr. Craig Koniver’s Food Sensitivy Test please fill out the information below. It will only take 5 minutes. If you have any questions, please call us at (877) 235-3540. These results help us determine if Dr. Koniver’s Food Sensitivity Test is right for you. We appreciate your time, thank you!

  1. (required)
  2. 2. We'll need to contact you to get the this process moving. May we contact you by phone?



  4. (required)
  5. 4. Do you currently have Health Insurance?
  7. 5. Who is your current Health Insurance Provider?
  11. 8. Are you awakened between the hours of 1:00 am and 5:00 am with the following symptoms: headache, dizziness, stomach cramps, bloating?
  13. 9. Does any member of your family have the following?
  15. 10. During childhood, did you have any of the following?
  17. 11. Were you told that you had colic feeding problems as a baby?
  19. 12. Do you have itching of the skin, palate, or roof of the mouth and how often does it occur?




  21. 13. Do you notice swelling of the ankles, feet, hands, or face on arising in the morning?
  23. 14. Do you ever have a full meal in the middle of the day?
  25. 15. Do you ever experience fatigue 1 to 2 hours after a meal?




  27. 16. Do you ever have a dry cough?




  30. 18. Do you have severe migraine headaches?




  32. 19. Do you have excessive chilling when a sudden change in temperature occurs?
  34. 20. Do you have sinus headaches?
  36. 21. Do you have headaches in the back of your head?
  38. 22. Do you ever have gas, belching, bloating after meals, or cramps?




  40. 23. Have you noticed numbness of the face, arms, or legs at periodic intervals for no apparent reason or cause?




  42. 24. Do you have drowsiness, headache, or bloating after the ingestion of a cocktail, beer, or wine?
  44. 25. Are you allergic to penicillin?
  46. 26. Do you ever have any diarrhea, even mild or intermittent?




  48. 27. Do you ever have repeated symptoms on awakening in the morning such as a headache?
  50. 28. Can you make the symptoms go away by eating or drinking any particular food, such as coffee or cola?
  53. 30. Do you ever clear your throat?




  55. 31. Does your weight ever increase or decrease 4 –5 pounds in a 1-week period?
 

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