ILIT™ Pre-Assessment Form

Thank you for taking this courageous step toward lasting allergy relief with Intralymphatic Immunotherapy (ILIT™). We believe your symptoms are real, your experiences matter, and you deserve personalized care that works.

This assessment is the first step in our Immune Confident journey together:

✨ RECOGNIZE: We'll help you identify your unique allergy patterns and uncover the true drivers of your symptoms

✨ RECLAIM: Discover if ILIT™ can help you take back control of your immune response

✨ REBEL: Move beyond temporary solutions to address the root of your allergies

✨ RISE: Create the foundation for lasting immune confidence and symptom freedom

Please share your story with us through this brief 5-minute assessment. Our medical team will carefully review your responses, honoring your unique experience and helping you determine if ILIT™ is the right path for your healing journey.

Your information remains completely confidential and will be reviewed with compassion by our licensed medical professionals.

Let's Connect

We'd love to learn who you are so we can reach out about your personalized assessment results.

Full Name *

Date of birth *

Age *

Sex Assigned at Birth *

Gender Identity

Pronouns

Phone *

Email *

Your Location Journey

Understanding your location helps us create a realistic treatment plan that respects your geographic needs.

What state do you currently reside in? *

If you are not an Ohio resident, are you willing to travel to Ohio for your ILIT treatments? *

Yes, I am willing to travel to Ohio for all treatments

No, I cannot travel to Ohio

I am an Ohio resident

Unsure, I would like to discuss options

We'll work with you to create a comfortable travel experience if needed.

Recognizing Your Symptoms

Sharing your symptoms helps us understand your unique experience with allergies and how ILIT might benefit you.

What are your primary allergy symptoms that you are seeking treatment for? *(Select all that apply)

List other symptoms that are not in the list above:

Identifying Your Triggers

Understanding your specific allergen triggers helps us customize your ILIT protocol for optimal results.

What allergens do you believe you are allergic to? *(Select all that apply or list known allergens)

List other allergens that are not in the list above & specify if needed:

The Impact on Your Life

We want to understand how allergies are affecting your quality of life so we can focus on what matters most to you.

How long have you been experiencing these allergy symptoms? *

Your allergy timeline helps us understand the progression of your symptoms

How do your allergy symptoms impact your daily life? *

Tell us about activities you avoid, adjustments you've made, or ways your symptoms affect your work, relationships, sleep, or emotional wellbeing.

What are your goals for ILIT? What do you hope to achieve with this treatment? *

Your Previous Testing Experience

Information about past testing helps us build on existing knowledge rather than starting from scratch.

Have you had allergy testing (skin prick testing or blood tests like IgE tests) in the past? *

Yes

If yes, when was your most recent allergy testing done (approximate month/year)?

If yes, where was it done (clinic/doctor name, if you recall)?

If you recall, what allergens were you found to be allergic to based on testing?

Are you able to provide a copy of your most recent allergy test results? *

Yes

Unsure if I can find them

Your Treatment History

Understanding your past treatment experiences helps us better understand what hasn't worked and why ILIT might be right for you.

Which of the following allergy treatments have you tried in the past? *

Over-the-counter medications (e.g., antihistamines, nasal sprays)

Prescription medications (e.g., nasal steroids, leukotriene inhibitors)

Allergen avoidance measures

Allergy shots (subcutaneous immunotherapy - SCIT)

Sublingual immunotherapy (SLIT - drops or tablets)

None of the above

(Select all that apply)

Other treatments that are not in the list above:

For any treatments selected above, please provide more details:

If you used Over-the-counter medications:

Which medications did you try, how long did you use them, and what was your experience?

If you used Prescription medications:

If you tried Allergen avoidance measures:

If you received Allergy shots (SCIT):

If you received Sublingual immunotherapy (SLIT):

Your Current Treatment Approach

Knowing your current management strategies helps us integrate ILIT into your existing care plan.

Are you currently receiving any form of allergy treatment? *

Yes

Please select one.

If yes, what current allergy treatments are you using?

Your Complete Health Picture

A holistic view of your health helps us ensure ILIT is safe and appropriate for your unique situation.

Do you have, or have you ever had, any of the following conditions? *

Cardiovascular disease (e.g., heart attack, congestive heart failure, unstable angina, uncontrolled high blood pressure, significant arrhythmias)

Autoimmune disease (e.g., lupus, rheumatoid arthritis, multiple sclerosis)

Cancer (current or recent history, especially if undergoing chemotherapy/immunotherapy)

Chronic infectious diseases (e.g., hepatitis, tuberculosis, HIV)

Severe atopic dermatitis (eczema)

Significant kidney (renal) disease

Significant liver (hepatic) disease

Bleeding disorders

None of the above

Select all that apply.

Other significant medical condition (please specify):

Your Current Medications

Understanding your medication regimen helps us ensure ILIT will integrate safely with your current care.

Are you currently taking any beta-blocker medications? *

Yes

Unsure

(e.g., for high blood pressure, heart conditions, migraines like Propranolol, Metoprolol, Atenolol). Beta-blocker use can interfere with the treatment of anaphylaxis.

Are you currently taking any ACE inhibitor medications? *

Yes

Unsure

(e.g., for high blood pressure, heart conditions like Lisinopril, Ramipril)

Are you taking any medications that suppress your immune system? *

Yes

Unsure

Please select one.

Please list ALL current medications you are taking, including prescription, over-the-counter, vitamins, and supplements. Include dosage if known.

Your Reaction History

Understanding past reactions helps us take appropriate precautions for your safety.

Have you had any significant reactions to vaccines or injections in the past? *

Yes

Please select one.

If yes, please describe the reaction.

Your Anaphylaxis History

If you've experienced anaphylaxis, we'll create additional safeguards for your ILIT treatment.

Have you ever experienced anaphylaxis (a severe, life-threatening allergic reaction)? *

Yes

Please select one.

If yes, what was the trigger for the anaphylactic reaction?

Your Pregnancy Considerations

Your reproductive status helps us time your treatment appropriately.

Are you pregnant, or planning to become pregnant in the next 4 months? *

Yes

Not Applicable

ILIT is generally contraindicated during pregnancy; initiation is typically delayed until after pregnancy.

Your Comfort with the Procedure

We want to address any concerns you have about the treatment process before you begin.

ILIT typically involves a series of 3 injections, usually spaced about 4 weeks apart, directly into a lymph node (often in the groin area) under ultrasound guidance. How would you rate your comfort with this type of procedure? *1 = Very Uncomfortable, 3 = Neutral, 5 = Very Comfortable

Do you have any upcoming travel or significant commitments that might interfere with the treatment schedule (3 injections over approximately 8 weeks, plus potential follow-ups)? *

Yes

If yes, please briefly describe any potential scheduling conflicts.

Exploring Another Option for Care

We understand that traveling to Ohio isn't feasible for everyone. We do have one premium, concierge-level alternative for receiving care in your location.

Would you be open to exploring if a practitioner could travel to you for treatment? This would involve a significant additional investment to cover all travel, lodging, and logistical costs. *

Yes, I'd like to learn more about this option

No, that would not be feasible for me

Preparing for Your ILIT Journey

This final information helps us understand your expectations and how we can best support you.

Our experience shows that the most profound results occur when ILIT is paired with a comprehensive plan that addresses other contributing factors to your immune health. Which approach are you most drawn to at this time? *

The ILIT Protocol

The AIR-ILIT™ Accelerator Program

I'm not sure yet.

Please select one.

To help us guide you to a sustainable care plan, please select the investment you are prepared to make for your allergy transformation over the next 3-6 months. (All our services are HSA/FSA eligible). *

~$4,000 (Aligns with the ILIT Protocol)

~$6,000+ (Aligns with the AIR-ILIT™ Accelerator Program)

I would like to discuss payment plan options

I'd prefer to discuss the investment during my consultation

Please select one.

Do you have any concerns or further questions about intralymphatic immunotherapy at this time that you would like to note for your consultation? *

How did you hear about our ILIT program? *

Understanding your journey to us helps us better serve others like you.