Form Calculation

"*" indicates required fields

Name*

Symptom Survey

MILD = occurs rarely, MODERATE = occurs several times a month, SEVERE = constant

Section A

Section B

Section C

Section D

Section E

Section F

Section G.1

Section G.2

Section G.3

Section G.4

Section G.5

Section G.6

Section H

Section I

Nutritional ID Questionnaire

If your score is between 6 thru 14, you would begin your Base Nutritional Plan as a Protein Type
If your score is between -5 thru 5, you would begin your Base Nutritional Plan as a Mixed Type
If your score is between -14 thru -6, you would begin your Base Nutritional Plan as a Veggie Type

Gut/Gluten Questionnaire

Check all that apply
If your score is 4 or Less, your potential for gluten intolerance is: Not likely
If your score is between 5 thru 8, your potential for gluten intolerance is: Suspected
If your score is 9 or more, your potential for gluten intolerance is: Very likely