Food Intolerance Action Plan Form
Provide details to help create a practical plan for managing your food intolerance symptoms.
Full Name
*
First Name
Last Name
Age
*
Primary Food Intolerance(s)
*
Lactose
Gluten
Fructose
Histamine
Other
Describe your main symptoms
*
How often do you experience symptoms?
*
Daily
Several times a week
Weekly
Occasionally
When do your symptoms usually occur?
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Immediately after eating
Within 1-2 hours after eating
Later in the day
Varies
How severe are your symptoms?
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Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Current strategies you use to manage symptoms
Known triggers or situations that worsen symptoms
What is your main goal for this action plan?
*
Submit Action Plan
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