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Medications and Food Supplements
Are you taking any medicines, vitamins, minerals, herbs, food supplements, homeopathic remedies, amino acids or glandulars?   Yes No
If yes, please list     
Have you had any reactions to medicine some, vitamins, minerals, herbs, food supplements, homeopathic remedies, amino acids or glandulars?   Yes No
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Nutrition
How many 12 oz. glasses of water do you drink each day? 0 - 2 3 - 5 > 5
How many 6 oz. glasses of juice do you drink each day? 0 - 2 3 - 5 > 5
How many 12 oz. glasses of coke do you drink each day? 0 - 2 3 - 5 > 5
How many servings of bread, rice, pasta do you eat each day? 0 - 2 3 - 5 > 5
How many servings of vegetables do you eat each day? 0 - 2 3 - 5 > 5
How many servings of fruit do you eat each day? 0 - 2 3 - 5 > 5
How many servings of milk and cheese do you eat each day? 0 - 2 3 - 5 > 5
How many servings of meat, poultry and fish do you eat each day? 0 - 2 3 - 5 > 5
How many servings of dry beans, eggs and nuts do you eat each day? 0 - 2 3 - 5 > 5