Oral Ulcer Diet Recommendation Form
Please provide the following information to help us recommend the most suitable diet choices for oral ulcer management.
Full Name
First Name
Last Name
Age
*
How long have you been experiencing oral ulcers?
*
Please Select
Less than 1 week
1-2 weeks
More than 2 weeks
What is your current level of oral pain or discomfort?
*
No pain
1
2
3
4
5
6
7
8
9
Severe pain
10
1 is No pain, 10 is Severe pain
Do you have any known food allergies or dietary restrictions?
Gluten
Dairy
Nuts
Vegetarian
Vegan
Other
Which foods or drinks seem to worsen your oral ulcers?
Which foods or drinks are easier or more comfortable for you to consume?
Are you currently taking any medications or have any medical conditions that affect your diet?
How would you describe your current hydration status?
Well hydrated
Somewhat hydrated
Not hydrated
Any additional information relevant to your oral ulcers or diet?
Submit
Should be Empty: