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DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com


The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Food Introduction
Response (FIR)

PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:


Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com

Copyright 1999 Donna F. Smith

INSTRUCTIONS: Test only one food or beverage at a time. Wait four days before testing another food or beverage. When recording symptoms, these are symptoms you have experienced from 30 minutes to 3 days after ingesting the Test Food.

Time: Record the time the test was performed  

Test Food:
Name of food tested (carrot, lima beans, milk, etc.)

Pulse: Record your pulse before and 30 minutes after ingesting Test Food.
Before:  30 minutes after:  

Energy Level: Put a number from 0-10 (0 = No energy to 10 = Vibrant Energy)
indicating how you feel 30 minutes after ingesting Test Food. Pay attention to your energy level over the next 72 hours as with some Test Foods there may be a delayed energy response. If you have a delayed response, explain this in the "Other Responses" section and include a number from 0-10 for your delayed energy response.


Food Score: Put a number from 0-10 (0 = Dislike Test Food to 10 = Love Test) In "Other Responses," indicate what you dislike to love. Dislike or love taste, texture, feel, smell, or everything about the Test Food.


Digestion: List any gastro-intestinal symptoms, such as indigestion, gas, heartburn, acid stomach, burping, stomach cramping, bloating, etc.


Bowel Function: Record the number and time of bowel movements you have for the next three days after ingesting the Test Food. Also indicate if your bowel movements are solid or breaks up, small or large, soft or hard, runny, loose, pellets, stronger odor than usual, or
diarrhea-like.


Head: Record any symptoms in the head, such as headache, pressure in the head, mental confusion, dizziness, blurred vision, etc.


Sinus/Chest/Throat: Sinus/Chest/: Record any symptoms in your sinuses or chest, such as sinus, Throat: throat or chest congestion, stuffy, runny or drippy nose, stuffed up, chest pain, sore throat, hoarseness, sinus pressure, etc.


Kidney/Bladder/Skin Function: Kidney/Bladder: Record symptoms in your kidneys, bladder, or on your skin. Skin Function: For example, pain, difficulty, or incontience urination, difficulty in holding urine, drippling, pain, skin sores, rash, itch, etc.


Other Responses: Record any other response you may notice from 30 minutes to 3 days after ingesting Test Food. Also, use this space to provide additional comments.

Copyright, 1999 Donna F. Smith