Alta's Autoimmunue Health Self-Assessment

Alta's Autoimmune Assessment

Please fill out this form to the best of your knowledge so we can better assist you. Disclaimer - this is not a formal diagnosis of any kind. We are not physicians and autoimmune disorders cannot be determined simply through a self-assessment. However, many people think these symptoms are "normal" so this assessment is meant to bring awareness to any potential abnormalities, as well as give you guidance for how to improve your condition with diet and lifestyle changes.
Name*

First NameLast Name
Email*
example@example.com
Gender at Birth*

MaleFemale
Age*
Height (feet inch)*
Weight (lb)*
Which of these symptoms have you experienced? (check all that apply)*

FatigueJoint Pain or SwellingSkin ProblemsAbdominal PainDigestive IssuesRecurring FeverSwollen GlandsBlurred VisionLoss of VisionImpaired CoordinationFrequent UrinationUrgent Bowel MovementsConstipationWeight gainWeight lossDry Mouth or Dry EyesDiarrhea, Bloating, or Excessive GasAnemiaOther
Have you been formally diagnosed with any of these autoimmune conditions?*

Crohn's DiseaseIBSLupusHashimoto'sSjogren'sRAEczema or PsoriasisOther
Do any of these risk factors apply to you? (be honest. no judgment here we just want to help)*

I am a smokerI am overweightI have a family history of autoimmune diseaseI have had bacterial or viral conditions throughout my lifeI take prescription medications (unrelated to the symptoms)
Have you taken any of these steps already to improve your symptoms?*

Over the counter medicationsConsulted a functional medicine doctorConsulted a primary care physician or other medical doctorMade changes to dietIncreased/reduced/changed exercise routineHad a medical procedureTaking prescription medications specific to the condition
If yes to prescription medications, which one(s)?
Phone #. These conditions are highly complex and incredibly personal. We will have more questions for you to help guide you, so we will need a valid U.S. phone number or some other way to message you directly (not email). Please include that here. *
If you are not in the United States, we will give you another option on the next page to get in touch with us to answer any questions on your condition
Should be Empty:

Alta's Autoimmune Assessment