Name:*
E-mail*
Phone:*
Address:*
Height:*
Weight:*
Gender:*
Age:*
Date of birth (month/day/year):*


What are your top 3 priorities for your health right now?
What are you willing to do to achieve your health goals? What are you NOT willing to do?
What, if anything, have you tried to help with your health issues? (Any diet changes or other therapies?)
Has your doctor diagnosed you with any health conditions? If so, please list.
Are you taking any medications or supplements? If so, please list (and specify the dose you're currently taking).
On a scale of 1-10 (with 10 being the worst), how stressful would you say your day-to-day life is on average?
How many days of work/school have you missed in the last month due to illness?


For the following fields, please rate your symptoms based on your experience OVER THE PAST MONTH.


Constitutional Symptoms

Fatigue (tired, sluggish):
Hyperactive (nervous energy):
Restless (can't relax/sit still):
Daytime sleepiness:
Insomnia at night:
Malaise (feeling lousy):
Seizures:


Emotional/Mental Symptoms

Depression:
Anxiety (fears, uneasiness):
Mood swings (rapid, distinct changes):
Irritability (anger, hostility):
Forgetfulness:
Lack of concentration/focus:
Low sex drive:


Head/Ears

Headache (not migraine):
Migraine:
Earache:
Ear infection:
Ringing in ears:
Itchy ears:
Discharge from ears:
Sensitivity to sound:


Skin

Blemishes, acne:
Rashes, hives:
Eczema, psoriasis:
Rosy cheeks:
Flushing:
Itchy skin:


Nasal/Sinus

Post nasal drip:
Sinus pain:
Runny nose:
Stuffy nose:
Sneezing:


Mouth/Throat

Sore throat:
Swollen throat:
Swelling/burning of lips/tongue:
Gagging or throat clearing:
Lesions/canker sores:
Difficulty swallowing:


Lungs

Wheezing:
Chest congestion:
Dry cough:
Wet cough:
Shortness of breath:


Eyes

Red or swollen eyes:
Watery eyes:
Itchy eyes:
Dark circles or baggy eyes:
Sensitivity to light:
Aura:


Genitourinary

Increased urinary frequency:
Painful urination:
Bladder pain:
Bedwetting:


Musculoskeletal

Joint pain/aching:
Stiff joints:
Muscle aches:
Stiff muscles:
Tics (facial or otherwise):
Muscle spasms:
Muscle cramps:


Cardiovascular

Irregular heartbeat:
High blood pressure:


Digestive

Heartburn/reflux:
Stomach pains/cramps:
Intestinal pains/cramps:
Constipation:
Diarrhea:
Bloating sensation:
Gas (of any kind):
Nausea:
Vomiting:
Painful elimination:


Weight Management

Fluctuating weight:
Food cravings:
Water retention:
Binge eating or drinking:
Purging (all methods):


What other health info would you like to share? (Feel free to list any symptoms that were not already mentioned.)



Please type your initials in the following fields to indicate that you've read and agree to the corresponding statements:


I understand that the LEAP protocol involves following a strict diet for the first few weeks and that deviating from this diet will affect my success on this program.*
I understand that the diet is most restrictive during the first 10-14 days and gets progressively less restrictive throughout the program. I understand that I may be limited to only 20-30 foods for the first 10-14 days of the eating plan.*
I understand that I will be required to avoid any foods that are not tested by the Mediator Release Test for the first few weeks of the eating plan.*
I understand that I will be required to be diligent about reading food labels/ingredient lists and I understand that I will need to keep records of everything that I'm eating (for at least the first few weeks).*
I understand that, for best results, I will need to cook my meals from scratch as much as possible.*
I understand that I may need to change certain personal care products (and, in some cases, household products) if they contain ingredients that I'm sensitive to.*
I understand that MRT's results are reflective of what's going on in my body right now and that these test results can change over time. I understand that I'll have better success on the program if I start the LEAP diet protocol within 4 months of getting tested. If I delay starting the diet significantly, I understand that I may need to get re-tested.*

Which program package are you interested in?*

Would you like to schedule a complimentary phone consult to go over the logistics of the program in more detail?*

By submitting this form, you agree to send the above information electronically to Amanda Austin to review for the purposes of screening for eligibility for this program. After reviewing your responses, Amanda will contact you at the e-mail address that you provided on this form. By submitting this form, you also understand that you are agreeing to use electronic forms of communication and that there are always limitations with regards to the security/privacy of communicating through e-mail. Amanda takes steps to safeguard all of your health information - Amanda will never share your health information with other parties without your explicit consent. For more info about how Amanda protects your privacy, please visit getwellified.com/privacy/.

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