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MAST CELL QUESTIONNAIRE

Check “Yes” if you have the following symptoms.

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Question 1 of 9

Symptom: Abdominal Pain/Bloating

A

YES

B

NO

Question 2 of 9

Symptom: Dermatographism:  Make a scratch on your forearm.  Does the scratch turn pink or red?

A

YES

B

NO

Question 3 of 9

Symptom: Headache

A

YES

B

NO

Question 4 of 9

Symptom: Poor Concentration and Memory

A

YES

B

NO

Question 5 of 9

Symptom: Diarrhea

A

YES

B

NO

Question 6 of 9

Symptom: Naso-ocular Symptoms

A

YES

B

NO

Question 7 of 9

Symptom: Asthma

A

YES

B

NO

Question 8 of 9

Symptom: Facial flushing with exercise

A

YES

B

NO

Question 9 of 9

Symptom: Anaphylaxis

A

YES

B

NO

Confirm and Submit