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
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First Name
Last Name
Email
*
example@example.com
Gender at Birth
*
Male
Female
Age
*
Height (feet inch)
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Weight (lb)
*
Which of these symptoms have you experienced? (check all that apply)
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Fatigue
Joint Pain or Swelling
Skin Problems
Abdominal Pain
Digestive Issues
Recurring Fever
Swollen Glands
Blurred Vision
Loss of Vision
Impaired Coordination
Frequent Urination
Urgent Bowel Movements
Constipation
Weight gain
Weight loss
Dry Mouth or Dry Eyes
Diarrhea, Bloating, or Excessive Gas
Anemia
Other
Have you been formally diagnosed with any of these autoimmune conditions?
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Crohn's Disease
IBS
Lupus
Hashimoto's
Sjogren's
RA
Eczema or Psoriasis
Other
Do any of these risk factors apply to you? (be honest. no judgment here we just want to help)
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I am a smoker
I am overweight
I have a family history of autoimmune disease
I have had bacterial or viral conditions throughout my life
I take prescription medications (unrelated to the symptoms)
Have you taken any of these steps already to improve your symptoms?
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Over the counter medications
Consulted a functional medicine doctor
Consulted a primary care physician or other medical doctor
Made changes to diet
Increased/reduced/changed exercise routine
Had a medical procedure
Taking 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
Format: (000) 000-0000.
Submit
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