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Evaluation Form

Elissa Kulpers

Bloodwork

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Please indicate foods you dislike by checking the boxes below. List allergies in the box at the bottom.

Meat:
Nuts/Seeds:
Eggs & Poultry:
Legumes:
Fish:
Breads/Rice:
Fats:
Starches:
Fruit:
Miscellaneous
General:
Vegetables:
Do You Have the following Equipment?
Salads:

Food Journal

You must fill every field.  If the field does not apply to you, please type N/A

Day 1

Day 2

Day 3

Day 4

Medications & Supplements

Contact Information

Healthcare Providers (doctors, dentist, naturopath, chiropractor, etc.)

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