Allergies
Please record what you eat in a typical day:
How many servings do you eat in a typical week of these foods:
How much stress do each of the following cause on a daily basis
(Rate on scale of 1-10, 10 being highest)
Symptom Review
Please check if these symptoms occur presently or have occurred in the last 6 months
Current medications (include prescription and over-the-counter)
Nutritional supplements (vitamins/minerals/herbs etc