Siphon Draw Apothecary

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Food Sensitivity Questionnaire

Please check all boxes below that apply to you at any time of your life

Food Allergies(Required)

Ear Itching or Infections

Dark circles under eyes

Rashes, Eczema

Itchy Skin

Dry Skin

Joint Pain

Diarrhea

Brain Fog

Constipation

Abdominal Pain

Acne

Migrane Headaches

Bloating

Gas

Nose Bleeds

Asthma

Irritable/Inflammatory bowel

Acid reflux

Itchy eyes

Fatigue (2+ hrs after eating)

I do not remember ever experiencing any of these symptoms

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Email

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Number

Name

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