ILIT™ Pre-Assessment Form

Thank you for your interest in Intralymphatic Immunotherapy (ILIT™) — a next-generation allergy treatment option for lasting relief.

Please complete this short survey to help our medical team assess your eligibility and prepare for your consultation. It only takes 5–10 minutes and ensures you receive personalized, safe, and effective care.

Your information is confidential and will be reviewed only by licensed medical professionals.

If you have had testing, please refer to your results if possible.
1 = Mild, 5 = Severe

Allergy History & Previous Treatments

For any treatments selected above, please provide more details:

Medical History

Uncontrolled or severe asthma is often a contraindication for ILIT.
(e.g., for high blood pressure, heart conditions, migraines like Propranolol, Metoprolol, Atenolol). Beta-blocker use can interfere with the treatment of anaphylaxis.
(e.g., for high blood pressure, heart conditions like Lisinopril, Ramipril)

Lifestyle and Expectations

1 = Very Uncomfortable, 3 = Neutral, 5 = Very Comfortable