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Nutrition Survey

*Name, E-mail, and Phone are required

Instructions:

Number the lines that apply to you with either a 1, 2, or 3.

1) For MILD Symptoms (Occur once or twice a year)

2) For MODERATE Symptoms (Occur several times a year)

3) For SEVER Symptoms (You are aware of it almost constantly)

GROUP 1

GROUP 2

GROUP 3

GROUP 4

GROUP 5

GROUP 6

GROUP 7(A)

GROUP 7(B)

GROUP 7(C)

GROUP 7(D)

GROUP 7(E)

GROUP 7(F)

FEMALE ONLY

MALE ONLY