Red Meat |
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Wheat (White or Whole) |
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Sweets and sugars |
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Sodas |
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Coffee. Teas, Cokes (diet or not) |
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Salt or Salted Foods |
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Dairy Foods |
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Alcohol (including wine) |
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Poultry |
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Nutrasweet (sweetners) |
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Pork |
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Vegetables |
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| Fish |
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Fast food |
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| Fried Foods & Cooked fats |
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Fruit |
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| Describe a typical Breakfast |
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| Describe a typical lunch |
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| Describe a typical dinner |
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| What kind of water do you drink and HOW MUCH of it a day (cups)? |
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| List all nutritional supplements you are taking |
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| List all medications you are taking |
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3. General Health Practices |
1. How much sleep do you get each night on the average?
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2. Do you exercise? How much?
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3. Do you feel that you are under stress? If so, briefly explain.
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4. How often does your bowel eliminates?
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5. Please list your current health concern
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