Name: __________________________________Age: ____Sex ...

Do you develop symptoms after or drinking or eating certain foods? Yes-2 No-0. Do you sometimes feel stimulated,hyperactive,or fatigued after meals? Yes-2 No-0. Do you have dark circles under your eyes? Yes-2 No-0. Do you have a crease across the bridge of our nose? Yes-2 No-0. Total Score ................
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