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Patient Inquiry
Patient Information form
Sample Collection Date
First Name
Last Name
DOB
Gender
Male
Female
Email
Phone
Ethnicity
Caucasian
African American
Hispanic/ Latino
Ashkenazi Jewish
Hawaiian/Pacific Islander
American Indian/Native American
Asian
Mixed Race
Other
Current Eating Style
Omnivore:
Includes both plant and animal-based foods, offering a wide variety of nutrients.
Vegan:
Primarily consists of plant foods, but excludes all animal products and milk products.
Plant-Based:
Primarily consists of plant foods and may include milk and milk products, but excludes all other animal products.
Eggetarian:
A vegetarian diet that includes eggs for added protein and nutrients.
Nut-Free:
Excludes all tree nuts and peanuts to accommodate allergies or sensitivities.
Pollotarian:
Includes poultry and plant foods, while avoiding red meat and seafood.
Pescatarian:
Focuses on plant foods and seafood, excluding meat and poultry.
Lacto-Ovo Vegetarian:
A vegetarian diet that includes dairy and eggs for balanced nutrition.
Activity Level
Sedentary
Moderately Active
Active
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