Preliminary Questionnaire

Who were you referred by?

Are you currently taking any medication?
YesNo

If yes, please list.

Have you had chemotherapy within the last three years?
YesNo

Are you allergic to wheatgrass, alfalfa or barley grass?
YesNo

In general, please list what you are allergic to and any adverse reactions.

Do you have IBS or chronic diarrhea?
YesNo

What city and state do you live in?

 

Answers will remain completely confidential.