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Filtricine Food Test Questionnaire
Your information will be used for internal assessment only. We won't share your info with any third party.
Email address *
Phone Number *
Your answer
First Name *
Your answer
Last Name *
Your answer
Sex *
Filing Date *
MM
/
DD
/
YYYY
What is your age? *
Are you currently under the care of a physician? *
What type of cancer do you have? (if applies) *
Your answer
What stage is the cancer? (if applies)
Which of the following currently applies to you? *
Do you follow certain nutritional guidelines due to medical reasons? *
Please specify in Other section if Yes.
Have you ever been directed to follow certain nutritional guidelines due to medical reasons? *
Please specify in Other section if Yes.
Do you have any food sensitivities or allergies? *
Please specify food allergy in Other section if Yes.
What is your Body Mass Index (BMI)? *
Please express the number in xx.x format.
Your answer
Do you have chronic conditions with liver, kidney, and heart? *
Please specify food allergy in Other section if Yes.
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