New Patient Nutrition Assessment Form
Autoimmune condition (specify type) Bronchitis Cancer Chronic Fatigue Syndrome Crohn’s Disease or Ulcerative Colitis Depression Diabetes (Specify: Type I, II, Prediabetes, Gestational Diabetes) Dry, itchy skin, rashes, dermatitis Eczema Emphysema Epilepsy, convulsions, or seizures Eye Disease (please specify) Fibromyalgia ................
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