Food Sensitivities Chart
Reintroduce only one new food at a time. Ingest it twice in the same day and then wait for two to three days to see if you have a reaction. Check any symptoms that you may have on this chart. Pay special attention to digestion, bowel function, and energy levels. If you have symptoms that aren’t included on this chart, please note that as well. You may copy this form for more added foods in the future. You may also use the blank spaces for symptoms not listed.
| Sympton | Food | Date & Time | Food | Date & Time | Food | Date & Time |
|---|---|---|---|---|---|---|
| Bloating | ||||||
| Indigestion | ||||||
| Stomach Ache | ||||||
| Excessive Gas | ||||||
| Constipation | ||||||
| Diarrhea | ||||||
| Urinary / Bladder Problems | ||||||
| Headache / Migraines | ||||||
| Nasal Congestion | ||||||
| Post Nasal Drip | ||||||
| Asthma / Chest Congestion | ||||||
| Breathing Problems | ||||||
| Swelled Tongue | ||||||
| Cold Sores / Fever Blisters | ||||||
| Skin Rash / Hives / Acne | ||||||
| Inflammation | ||||||
| Joint Pain | ||||||
| Muscle Pain | ||||||
| Fatigue / Lethargy | ||||||
| Insomnia | ||||||
| Trilogy Medical Centers • Lean to Wellness • Food Sensitivities Form • 9.3.2015 | ||||||
This information is available as a PDF document.