MRT Food Frequency Questionnaire

This form assists me in designing your LEAP protocol. It is important that your phase 1 begins with foods that you are currently eating on a regular basis.

INSTRUCTIONS:

Score foods based on your experience over the PAST MONTH using the Scale of Frequency.
If you do not eat a food or almost never eat a food, you can leave that field empty.
Mark suspected adverse food reactions with an X and provide more information in the comments.

Scale of Frequency
0 = DO NOT eat a food or almost never eat a food
1 = RARELY (1 or less times per week)
2 = OCCASIONALLY (2 or 3 times per week)
3 = FREQUENTLY (4 or more times per week)
4 = DAILY

Adverse Food Reactions
X = Please mark all foods that you know or strongly suspect cause symptoms in any part of your body. This includes symptoms caused by disease states, food allergies, food sensitivities, and food intolerance, (such as Celiac's disease and lactose intolerance).

* Indicates required field

Your Unique2U Personal Indentification Code *

This form is being completed for: *

If you are not completing this form for yourself, please enter the person's relationship to you. *

Beans & Legumes

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Garbanzo Beans (Chick Peas) *

Soybeans or Soy Products *

Pinto Beans *

Green Peas *

Hummus *

Lentils *

Lima Beans *

Any additional comments or questions about Beans & Legumes: *

Any Adverse Food Reactions comments for Beans & Legumes: *

Meat & Poultry

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Beef *

Chicken *

Egg White *

Egg Yolk *

Lamb *

Pork *

Turkey *

Any additional comments or questions about Meat & Poultry: *

Any Adverse Food Reactions comments for Meat & Poultry: *

Seafood

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Catfish *

Clam *

Codfish *

Crab *

Salmon *

Scallop *

Shrimp *

Sole *

Tilapia *

Tuna *

Any additional comments or questions about Seafoody: *

Any Adverse Food Reactions comments for Seafood: *

Nuts & Seeds

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Almonds *

Cashews *

Hazelnuts *

Pecans *

Peanuts *

Pistachios *

Walnuts *

Sunflower Seeds *

Any additional comments or questions about Nuts & Seeds: *

Any Adverse Food Reactions comments for Nuts & Seeds: *

Dairy

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

American Cheese *

Cheddar Cheese *

Cottage Cheese *

Cow's Milk *

Goat's Milk *

Whey *

Yogurt *

Any additional comments or questions about Dairy: *

Any Adverse Food Reactions comments for Dairy: *

Vegetables

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Asparagus *

Beet *

Broccoli *

Cabbage *

Carrot *

Cauliflower *

Celery *

Cucumber *

Eggplant *

Green Pepper *

Lettuce *

Mushroom *

Onion *

Spinach *

Green Bean *

Sweet Potato *

Tomato *

White Potato *

Yellow Squash *

Zucchini *

Any additional comments or questions about Vegetables: *

Any Adverse Food Reactions comments for Vegetables: *

Fruit

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Apple *

Apricot *

Avocado *

Banana *

Blueberry *

Cantaloupe *

Cherry *

Cranberry *

Grape *

Grapefruit *

Honeydew *

Mango *

Olive *

Orange *

Papaya *

Peach *

Pear *

Pineapple *

Plum *

Prune *

Raisin *

Raspberry *

Strawberry *

Watermelon *

Any additional comments or questions about Fruit: *

Any Adverse Food Reactions comments for Fruit: *

Grains

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Amaranth *

Barley *

Buckwheat *

Corn *

Kamut *

Millet *

Oat *

Quinoa *

Rice *

Rye *

Spelt *

Wheat *

Any additional comments or questions about Grains: *

Any Adverse Food Reactions comments for Grains: *

Flavor Enhancers & Miscellaneous

0 = Do Not 1 = Rarely 2 = Occasionally 3 = Frequently 4 = Daily X = Adverse Food Reactions

Basil *

Black Pepper *

Butter *

Cane Sugar *

Carob *

Cayenne Pepper *

Cinnamon *

Cocoa *

Coconut *

Cumin *

Dill *

Garlic *

Ginger *

Honey *

Leek *

Lemon *

Maple *

Mint *

Mustard *

Olive Oil *

Oregano *

Paprika *

Parsley *

Sesame *

Turmeric *

Vanilla *

Yeast Breads *

Coffee *

Tea *

Tapioca *

Any additional comments or questions about Enhancers & Miscellneous: *

Any Adverse Food Reactions comments for Enhancers & Miscellaneous: *

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