4) In each of the areas listed below (as applicable) please indicate if it was easy or challenging to follow the recommendations provided during our last visit. Use a scale of 1-10, with one being the easiest and ten being the hardest.
It is important to keep an accurate record of your usual food and beverage intake as a part of your treatment plan. Please complete this Diet Diary for 3 consecutive days including one weekend day.
Add new row
The Toxicity and Symptom Screening Questionnaire identifies symptoms that help to identify the underlying causes of illness, and helps you track your progress over time. Rate each of the following symptoms based upon your health for the past 30 days. If you are taking this for a repeat visit, record your symptoms for the past 48 hours ONLY.
0 = Never or almost never have these symptoms
1 = Occasionally have it, effect is not severe
2 = Occasionally have it, effect is severe
3 = Frequently have it, effect is not severe
4 = Frequently have it, effect is severe
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2024 Hush Communications Canada Inc.