Mast Cell Activation Syndrome

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1 Mast Cell Activation Syndrome Clinical Questionnaire Description Today s Date: Patient Name: Please indicate yes or no for the following symptoms and traits: (If you are not familiar with a particular trait(s), then check No as it does not apply to you) General I have been sick for as long as I can remember Vomiting as an infant Abdominal pain as an infant Frequent infections, cold, viruses, gut viruses as an infant, adolescent or adult Frequent fatigue and malaise Frequent fevers Edema water accumulation in different parts of the body Waxing and waning of symptoms Food, drug, and chemical intolerances (especially fragrances) Sense of being cold all the time Decreased wound healing Hypersensitivity to much in environment Weight gain or loss can go up and down Heat intolerance Insomnia Frequent family history of cancer especially intestinal or bone marrow (hematologic) General feeling inflamed Generalized lymphadenopathy (enlarged lymph nodes) Ears Ringing in ears (tinnitus) Eustachian tube dysfunction (blocked, popping ears)

2 Eyes Red eyes Irritated eyes Dry eyes Burning eyes Difficulty focusing vision Conjunctivitis Nose Nasal stuffiness Sinusitis Post nasal drip Hoarseness Laryngitis Nose bleeds (epistaxis) Intranasal sores Throat Vocal cord dysfunction Throat swelling Sores on tongue/mouth Itchy throat Burning mouth Difficulty swallowing Skin Hives Angioedema Skin flushing Itchiness Skin rashes Dermatographism (scratch the skin red welt arises)

3 Skin cont. Chronic itching Urticarial pigmentosa Flushing Easy bruising Reddish or pale complexion Cherry angiomata Patchy red rashes Red face when wake Cannot heal when cut Fungal skin infections Lichen planus Cardiovascular Fainting Fainting upon standing Increased pulse rate (tachycardia) Palpitations Spikes and drops in blood pressure, pulse or temperature High triglycerides Light headedness Dizzy Hot flushes POTS syndrome Respiratory Wheezing Asthma Shortness of breath Can t catch a deep breath Air hunger Dry cough

4 Respiratory cont. COPD Chronic interstitial fibrosis GI Tract Left upper abdominal pain Splenomegaly (enlarged spleen) Epigastric tenderness Nausea Vomiting Diarrhea and/or constipation Abdominal cramping and bloating Non-cardiac chest pain Malabsorption GERD/acid relux Cyclic vomiting syndrome Colonic polyps Gastric polyps Liver High bilirubin Elevated liver enzymes High cholesterol Neurological Numbness and tingling, especially hands and feet Headaches Migraines Tics or tremors Pseudo seizures True seizures

5 Waxing and waning brain fog Neurological cont. Memory loss Poor concentration Word finding difficulty Spells of cataplexy (suddenly becoming disconnected from and unresponsive to the world around) Musculoskeletal Muscle pain Fibromyalgia Increased osteopenia and osteoporosis Weakness Migratory arthritis (joint pain) Coagulation History of clots Deep vein thrombosis Increased bruising Heavy menstrual bleeding Bleeding nose Don t clot when cut Blood disorders Anemia Increased white cell count Decreased white cell count Decreased neutrophils Decreased lymphocytes Decreased platelets Reductions in CD4 helper lymphocytes Reductions in CD8 positive suppressor lymphocytes

6 Reductions or excesses of IgA, IgG, IgM, IgE Increased MCV (mean corpuscular volume) Psychiatry Anxiety Panic Depression OCD Decreased attention (ADD) Forgetful Insomnia Genitourinary Interstitial cystitis Recurrent bladder infections Sterile bladder infections Frequent urination Hormones Decreased libido Painful periods Heavy periods Infertility Decreased sperm counts Dental Deteriorating teeth Anaphylaxis Difficulty breathing Itchy hives Flushing or pale skin

7 Feeling of warmth Weak and rapid pulse Anaphylaxis cont. Nausea Vomiting Diarrhea Dizziness and fainting Common triggers include Specific foods and drinks (especially alcohol and high-histamine content foods) Temperature extreme Airborne smells including perfumes or smoke Exercise or exertion Emotional stress Procaine and dental anesthetic Anesthetic Reference Dr. Bruce Hoffman July 5 th, 2016

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