Please describe your typical diet and give me an idea of what you eat. Include beverages. This form is optional, but can give a lot of insight about your current state of health.
Please indicate if you consume the following and how often, (daily, times/week, rarely, never). Please note if you have any particular reactions to these products.
Do you have a personal history of
Environmental and/or chemical sensitivities, including mold?
Chronic fatigue syndrome
Multiple chemical sensitivity
Parkinson’s type symptoms
Alcohol or chemical dependence
Asthma or COPD
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