Create a PATIENT RECORD ID:
In the box to the RIGHT, please fill in as follows (example: ABCD84):
1st letter of your first name: A
1st letter of your surname or last name: B
1st letter of your mother's maiden name: C
1st letter of your city of birth: D
Last two digits of your birth year: 84

* must provide value

example: ABCD84

"I have read the participant information sheet and do not have any questions about participation. I voluntarily consent to participate in this study. I understand that future questions I may have about the research or my rights as a participant will be answered by study staff at 425-602-3306 or neuroresearch@bastyr.edu."
Do you consent to participate?
By consenting online, you no longer need to sign and mail in a paper copy of the consent form.

Yes

No

Country

* must provide value

United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo - Democratic Republic of the Congo - Republic of the Costa Rica Cote d'Ivoire Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Yemen Zambia Zimbabwe

Country within the United Kingdom

* must provide value

England Northern Ireland Scotland Wales

State or territory

* must provide value

Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Marianas Islands North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Virgin Islands Washington West Virginia Wisconsin Wyoming

Province

* must provide value

Alberta (AB) British Columbia (BC) Manitoba (MB) New Brunswick (NB) Newfoundland and Labrador (NL) Northwest Territories (NT) Nova Scotia (NS) Nunavut (NU) Ontario (ON) Prince Edward Island (PE) Quebec (QC) Saskatchewan (SK) Yukon (YT)

State

* must provide value

State , province, or region

Today M-D-Y

Date of multiple sclerosis diagnosis?

Today M-D-Y

What is the approximate month and year that you first began having symptoms that may have been related to multiple sclerosis, even before your diagnosis?

Today M-D-Y

In the past 6 months have you had any relapses that required hospitalization and/or steroid treatment?

No Yes

If yes, how many relapses have you had in the last 6 months?

1 2 3 4 5 6 More than 6

What is the current stage of MS diagnosis?

Clinically isolated syndrome (CIS or probable MS) Radiologically isolated event (RIS) Relapsing Remitting Multiple Sclerosis (RRMS) Secondary Progressive Multiple Sclerosis (SPMS) Primary Progressive Multiple Sclerosis (PPMS) Don't know

Disease modifying therapies

Symptom management medications

Have you followed any of these diets consistently in the last 6 months? (check all that apply)

If other, which type of diet do you follow?

On how many of the last seven days did you participate in at least 30 minutes of physical activity?

0 1 2 3 4 5 6 7

What kind of physical activity?

What "Other" activity do you do?

In the past 6 months, on average, how many hours a week did you spend doing vigorous physical activity, such as heavy lifting, aerobics, fast bicycling, or digging?

In the past 6 months, on average, how many days a week did you do vigorous physical activity?

0 1 2 3 4 5 6 7

In the past 6 months, on average, how many hours a week did you spend doing moderate physical activity, such as light lifting, bicycling at a regular pace?

In the past 6 months, on average, how many days a week did you do moderate physical activity?

0 1 2 3 4 5 6 7

In the past 6 months, on average, how many hours a week did you spend walking, either for exercise, work, or to get to and from places?

In the past 6 months, on average, how many hours a day did you spend sitting or reclining? (not including sleeping)

In the past 6 months, on an average week, how many hours did you spend doing housework, such as sweeping/mopping, vacuuming, and scrubbing surfaces?

In the past 6 months, on an average week, how many days did you participate in strength/resistance training, such as free weights, using weight machines, or using resistance bands?

0 1 2 3 4 5 6 7

In the past 6 months, on an average week, how many days did you participate in flexibility exercises, such as yoga or stretching?

0 1 2 3 4 5 6 7

Please estimate your MS-related disability:

No disability Mild Disability Moderate Disability Gait Disability Early Cane Disability Late Cane Disability Bilateral Support Wheelchair/Scooter Dependant Immobile

Please rate the severity of your symptoms over the past 7 days, on average. The more severe and debilitating the symptom, slide right. If you're not having that symptom, slide to the left.

MS Hug
(feeling of tight band constricting torso or limbs)

* must provide value

Bowel Dysfunction
(constipation, diarrhea, incontinence)

* must provide value

Bladder Dysfunction
(urinary urgency, inability to urinate, incomplete emptying or incontinence)

* must provide value

Sexual Dysfunction
(reduced libido, erectile dysfunction, inability to orgasm, etc.)

* must provide value

Visual Disturbance
(unclear vision, double vision, areas of blindness)

* must provide value

Muscle weakness
(decrease in muscle strength)

* must provide value

Paresthesia
(numbness and tingling)

* must provide value

Muscle Cramps
(spasticity)

* must provide value

Tremors

* must provide value

Walking difficulties

* must provide value

Balance

* must provide value

Dizziness
(vertigo)

* must provide value

Lhermitte's Syndrome
(electric sensation in neck that travels down spine when chin touches chest)

* must provide value

Pain
(general pain, acute or chronic)

* must provide value

Heat Sensitivity
(affected or sensitive to heat, uncomfortable during warmer temperatures)

* must provide value

Speech

* must provide value

Depression
(sadness or hopelessness)

* must provide value

Attention
(difficulty focusing or completing daily tasks)

* must provide value

Exercise Induced Weakness
(increased muscle weakness or fatigue after exercise or daily activity)

* must provide value

Cognitive
(memory problems, organizational problems, or difficulty multi-tasking)

* must provide value

Anxiety
(fear, worry, panic)

* must provide value

Fatigue
(tired, drowsy, exhaustion)

* must provide value

Sleep Disorders
(insomnia, sleep disturbances, etc.)

* must provide value

I get enough sleep most nights.

True

False

Please note your most bothersome MS symptoms:

I eat most meals at home.

True

False

True

False

I routinely prepare meals for others.

True

False

It is difficult to afford groceries.

True

False

I purchase the least expensive food.

True

False

I buy from local organic farmers

True

False

True

False

True

False

True

False

True

False

True

False

I avoid artificial sweeteners.

True

False

True

False

I avoid artificial colors, flavors, etc.

True

False

I go to church, synagogue, mosque, or other religious services.

True

False

True

False

True

False

True

False

I have carbs for breakfast.

True

False

I practice calorie restriction.

True

False

True

False

True

False

True

False

True

False

True

False

I see a physical therapist.

True

False

I take homeopathic remedies.

True

False

I see a therapist or counselor.

True

False

True

False

I get enough sleep most nights.

True

False

True

False

I can name 6 foods on the dirty dozen.

True

False

I practice stress management.

True

False

True

False

I have amalgam (silver) fillings.

True

False

True

False

True

False

True

False

True

False

True

False

True

False

I read an educational book.

True

False

I've tested the radon level in my home.

True

False

There is water damage in my house.

True

False

There is mold in my house.

True

False

In general, would you say your health is:...

5 Excellent

4 Very good

3 Good

2 Fair

1 Poor

In general, would you say your quality of life is:...

5 Excellent

4 Very good

3 Good

2 Fair

1 Poor

In general, how would you rate your physical health?...

5 Excellent

4 Very good

3 Good

2 Fair

1 Poor

In general, how would you rate your mental health, including your mood and your ability to think?...

5 Excellent

4 Very good

3 Good

2 Fair

1 Poor

In general, how would you rate your satisfaction with your social activities and relationships?...

5 Excellent

4 Very good

3 Good

2 Fair

1 Poor

In general, please rate how well you carry out your usual social activities and roles. (This includes activities at home, at work and in your community, and responsibilities as a parent, child, spouse, employee, friend, etc.)...

5 Excellent

4 Very good

3 Good

2 Fair

1 Poor

To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair?...

5 Completely

4 Mostly

3 Moderately

2 A little

1 Not at all

How often have you been bothered by emotional problems such as feeling anxious, depressed or irritable?...

1 Never

2 Rarely

3 Sometimes

4 Often

5 Always

How would you rate your fatigue on average?...

1 None

2 Mild

3 Moderate

4 Severe

5 Very severe

How would you rate your pain on average?...

0 No pain

1

2

3

4

5

6

7

8

9

10 Worst imaginable pain

Your date of birth:

* must provide value

Today M-D-Y

Male

Female

What is your current marital or partnership status?

Married

Divorced

Single

Domestic partnership with opposite sex

Domestic partnership with same sex

Widowed

Caucasian

Black

Hispanic

Native American

Asian / Pacific Islander

Other

Imagine a ladder with 8 rungs representing where people stand in the your country.
At the top of the ladder are the people who are best off - those who have the most money, the most education, and the most respected jobs. At the bottom are the people who are worst off - who have the least money, least education, and the least respected jobs or no job. The higher up you are on the ladder, the closer you are to the people at the very top; the lower you are, the closer you are to the people at the bottom.
Where would you place yourself on this ladder?
Please pick which rung you think you stand at this time in your life, relative to other people in your country.

#8 - Top Rung

#7

#6

#5

#4

#3

#2

#1 - Bottom Rung

The next few questions are about costs. Unless otherwise indicated, the amounts are assumed to be entered in US dollars. If you are not living in the United States, please indicate which currency you are using.

Activity costs (eg. gym, classes, memberships)

Highest grade level completed:

Less than 8th grade

Grades 9-11

Completed High School/GED

Technical school certification

Associate Degree

Bachelors Degree

Graduate / Professional degree

What is your family's income in past 12 months? (Select all that apply.)

Less than $20,000

Between $20-40,000

Between $40-60,000

Between $60-80,000

Between $80-100,000

Between $100-150,000

More than $150,000

How many miles is your home from the
nearest highway?

How many miles is your home from the
nearest agricultural area?

Have you ever had an IgG Food Allergy test?

Yes

No

Please list any foods that tested positive for
IgG antibodies.

How often do you consume these foods?

Never

Seldom

Sometimes

Regularly

N/A

Do you drink caffeinated beverages?

Yes

No

What is your preferred caffeinated beverage?

Do you drink brewed coffee (not decaffeinated and not including espresso drinks)?

Yes

No

In the past 6 months, on average, how often did you drink brewed coffee?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

sm

med

lrg

x-lrg

Do you typically put cream, half and half, or milk in your coffee? (does not include alternative milks such as soy or almond)

Yes

No

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your coffee?

Yes

No

Do you typically put sweetener or flavor in your coffee, such as flavored syrups or sugar? (does not include sugar-free options)

Yes

No

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your coffee?

Yes

No

Do you drink instant coffee (not decaffeinated)?

Yes

No

In the past 6 months, on average, how often did you drink instant coffee?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

sm

med

lrg

x-lrg

Do you typically put cream, half and half, or milk in your coffee? (does not include alternative milks such as soy or almond)

Yes

No

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your coffee?

Yes

No

Do you typically put sweetener or flavor in your coffee, such as flavored syrups or sugar? (does not include sugar-free options)

Yes

No

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your coffee?

Yes

No

Do you drink decaffeinated coffee (instant or brewed)?

Yes

No

In the past 6 months, on average, how often did you drink decaffeinated coffee?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

sm

med

lrg

x-lrg

Do you typically put cream, half and half, or milk in your coffee? (does not include alternative milks such as soy or almond)

Yes

No

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your coffee?

Yes

No

Do you typically put sweetener or flavor in your coffee, such as flavored syrups or sugar? (does not include sugar-free options)

Yes

No

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your coffee?

Yes

No

Do you drink caffeinated espresso drinks (latte, mocha, americano)?

Yes

No

In the past 6 months, on average, how often did you drink espresso drinks?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is any drink with 2 shots of espresso)

sm

med

lrg

x-lrg

Do you typically use alternative milk products in your espresso drink, such as soy milk, almond milk, or rice milk?

Yes

No

Do you typically put sweetener or flavor in your espresso drink? (does not include sugar-free options)

Yes

No

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your espresso drink?

Yes

No

Do you drink decaffeinated espresso drinks (latte, mocha, americano)?

Yes

No

In the past 6 months, on average, how often did you drink decaffeinated espresso drinks?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is any drink with 2 shots of espresso)

sm

med

lrg

x-lrg

Do you typically use alternative milk products in your decaffeinated espresso drink, such as soy milk, almond milk, or rice milk?

Yes

No

Do you typically put sweetener or flavor in your decaffeinated espresso drink? (does not include sugar-free options)

Yes

No

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your decaffeinated espresso drink?

Yes

No

Do you drink decaffeinated or herbal tea (instant, bottled or brewed, not green tea)?

Yes

No

In the past 6 months, on average, how often did you drink decaffeinated or herbal tea?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

sm

med

lrg

x-lrg

Do you drink green tea (not decaffeinated instant, bottled or brewed or herbal tea)?

Yes

No

In the past 6 months, on average, how often did you drink green tea?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

sm

med

lrg

x-lrg

Do you drink black tea such as Earl Grey or English breakfast (not decaffeinated instant, bottled or brewed)?

Yes

No

In the past 6 months, on average, how often did you drink black tea?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is 12 oz, 1 ½ cup, or tall)

sm

med

lrg

x-lrg

Do you typically put cream, half and half, or milk in your tea? (does not include alternative milks such as soy or almond)

Yes

No

Do you typically put alternative milk products, such as soy creamer, almond milk, or rice milk in your tea?

Yes

No

Do you typically put sweetener or flavor in your tea? (does not include sugar-free options)

Yes

No

Do you typically put sugar-free sweetener or flavor, such as splenda, sweeten-low, or truvia in your tea?

Yes

No

Do you drink caffeinated energy drinks, such as Red Bull, Monster, or Full Throttle?

Yes

No

In the past 6 months, on average, how often did you drink caffeinated energy drinks?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 16 oz can)

sm

med

lrg

x-lrg

Do you drink caffeinated energy shots, such as Red Bull Energy Shot or 5-Hour Energy?

Yes

No

In the past 6 months, on average, how often did you drink caffeinated energy drinks?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 2 oz bottle)

sm

med

lrg

x-lrg

Do you drink high caffeine sodas, such as Jolt or Mountain Dew?

Yes

No

In the past 6 months, on average, how often did you drink high caffeine sodas?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 20 oz bottle)

sm

med

lrg

x-lrg

Do you drink regular sodas with caffeine, such as Coke, Dr. Pepper, or Pepsi? (not diet)

Yes

No

In the past 6 months, on average, how often did you drink regular sodas with caffeine?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 20 oz bottle)

sm

med

lrg

x-lrg

Do you drink diet sodas with caffeine, such as Diet Coke, Diet Dr. Pepper, or Diet Pepsi?

Yes

No

In the past 6 months, on average, how often did you drink diet sodas with caffeine?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 20 oz bottle)

sm

med

lrg

x-lrg

Do you drink regular sodas without caffeine, such as caffeine-free Coke/Pepsi, Sprite or 7-up? (not diet)

Yes

No

In the past 6 months, on average, how often did you drink regular sodas without caffeine?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 20 oz bottle)

sm

med

lrg

x-lrg

Do you drink diet sodas without caffeine, such as caffeine free Diet Coke/Pepsi, Diet Sprite or Diet 7-up?

Yes

No

In the past 6 months, on average, how often did you drink diet sodas without caffeine?

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

What is your serving size? (Med serving size is one 20 oz bottle)

sm

med

lrg

x-lrg

Chicken - Serving size: 1 large or two small pieces

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Beef - 4 ounces or 1 med patty

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Pork - 4 ounces or 1 med patty

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Fresh Vegetables - 1/2 cup

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Canned Vegetables - 1/2 cup

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Fresh Fruit 1 medium 1/2 cup

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Cheese 1 slice or 1/2 cup

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Ice Cream 1 scoop or shake

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Nuts and Seeds 2 Tbsp spread or 1/4cup nuts

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Fish (non-fried) 4 ounces

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Fried foods (fries, chicken, etc) 3 ounces

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Non-diet soda12 ounces/1 can

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Diet soda12 ounces/ 1 can

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Spices (cinnamon, cloves, etc) 1/4 teaspoon

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Fresh Herbs (Thyme, Basil, etc) 1/4 tsp

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Liquor 1 oz or mixed drink

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

< 1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Soy (tofu, tempeh) 3 ounces

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Drink from plastic bottle

Never

<1 per month

1 per month

2-3x month

1 per week

2-4x week

Once daily

2-4x day

4-6x day

Pharmaceutical Prescriptions: Dose, Frequency, Brand, Duration

Supplements / Herbs / etc: Dose Frequency, Brand, Duration

What is your primary source of information
for Complimentary and Alternative Medical
Care?

ND MD DO DC ARNP Other

Other medical diagnosis or illnesses

Do you receive care or attend classes at any of
the following clinics?

Please contact me if there are any other studies for which I may be eligible.

Please tell us anything you think we should know.

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