(888) 669-5327
cs@nowleap.com
Practitioner Login
0 Items
Become a Lab Client
Patient Prescreening
About Oxford
About Oxford
Scientific Team / Medical Advisory Board
Management
Food Reactivity
Understanding Diet-Induced Inflammation
How Sensitivities Cause Inflammation
Leaky Gut and Sensitivity
Mediator Release Test
MRT III: The Future of Sensitivity Testing
The Patented Mediator Release Test
Collaboration with Sony Biotechnology, Inc.
MRT Food & Chemical Profiles
Specimen Collection & Shipping
Sample MRT Results
Research
Oxford Clinical & Technical Research
Publications & Research
IBS Research Study
IBD Research Study
Collaborate In Research
LEAP
How LEAP Works
Eating Plan Frequently Asked Questions
LEAP In The News
Patient Experiences
CLT Training
What CLTs Say
CLT Course Description
Pre-Purchase the Certified LEAP Therapist Training Course
LEAP Mentors
Contact Oxford
Draw Locator
Select Page
CLT Course Order Form (For Registered Dietitians Only)
by
admin
|
Dec 14, 2015
|
Blog
CLT Course Order Form (For Registered Dietitians Only)
How did you first hear about MRT?
Name
*
First
Last
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Canada
United States
Country
Daytime Phone
*
Evening Phone
Fax Number
Email
*
Male/Female
*
Male
Female
Age
Height (Inches)
Weight (lbs)
Is There A History of Allergies in your Family?
Yes
No
What are your main complaints (In Order of Importance):
Duration of Problem:
List All Medications (Prescription & OTC) Currently Taken on Regular or as Needed Basis:
Drug
Dosage
#Times/Day
Start Date
SCALE OF SYMPTOMS SUFFERED DURING THE LAST SIX (6) MONTHS
Select option
0
If You Do Not Suffer From This
AT ALL
Select option
1
If You Suffer
Occasionally
(less than twice a week) and It Is
Not Severe
Select option
2
If You Suffer
Frequently
(2 or more times per week) and It Is
Not Severe
Select option
3
If You Suffer
Occasionally
(less than twice a week) and When You Do It Is
Severe
Select option
4
If You Suffer
Frequently
(2 or more times per week) and When You Do It Is
Severe
CONSTITUTIONAL SYMPTOMS
Fatigue (tired, sluggish)
0
1
2
3
4
Hyperactive (nervous energy)
0
1
2
3
4
Restless (can’t relax/sit still)
0
1
2
3
4
Sleepiness during day
0
1
2
3
4
Insomnia at night
0
1
2
3
4
Malaise (feel lousy)
0
1
2
3
4
Lungs
“Wheezing” (Asthma/ Asthma-Like Symptoms)
0
1
2
3
4
Chest Congestion
0
1
2
3
4
“Non-Productive” Coughing
0
1
2
3
4
“Productive” Coughing
0
1
2
3
4
EMOTIONAL/MENTAL SYMPTOMS
Depression (feelings of hopelessness)
0
1
2
3
4
Anxiety (vague fears, uneasiness)
0
1
2
3
4
Mood Swings (rapid, distinct changes)
0
1
2
3
4
Irritability (anger, hostility)
0
1
2
3
4
Forgetfulness
0
1
2
3
4
Lack of Concentration/Focus
0
1
2
3
4
EYES
Red or Swollen Eyes
0
1
2
3
4
Watery Eyes
0
1
2
3
4
Itchy Eyes
0
1
2
3
4
“Dark Circles” or “Baggy”
0
1
2
3
4
GENITOURINARY
Increased Urinary Frequency
0
1
2
3
4
Painful Urination
0
1
2
3
4
HEAD/EARS
Headache (any kind)
0
1
2
3
4
Earache
0
1
2
3
4
Ear Infection
0
1
2
3
4
Ringing in Ear
0
1
2
3
4
Itchy Ears
0
1
2
3
4
Discharge from Ear
0
1
2
3
4
MUSCULOSKELETAL
Joint Pains/Aching
0
1
2
3
4
Stiff Joints
0
1
2
3
4
Muscle Aches
0
1
2
3
4
Stiff Muscles
0
1
2
3
4
Arthritis (Diagnosed)
0
1
2
3
4
SKIN
Blemishes, Acne
0
1
2
3
4
Rashes, Hives
0
1
2
3
4
Eczema
0
1
2
3
4
“Rosy” Cheeks
0
1
2
3
4
CARDIOVASCULAR
Irregular Heartbeat
0
1
2
3
4
High Blood Pressure (Diagnosed)
0
1
2
3
4
NASAL/SINUS
Post Nasal Drip
0
1
2
3
4
Sinus Pain
0
1
2
3
4
Runny Nose
0
1
2
3
4
Stuffy Nose
0
1
2
3
4
Sneezing
0
1
2
3
4
DIGESTIVE
Heartburn/Esoph. Reflux
0
1
2
3
4
Stomach Pains/Cramps
0
1
2
3
4
Intestinal Pains/Cramps
0
1
2
3
4
Constipation
0
1
2
3
4
Diarrhea
0
1
2
3
4
Bloating Sensation
0
1
2
3
4
Gas (of Any Kind)
0
1
2
3
4
Nausea, Vomiting
0
1
2
3
4
Painful Elimination
0
1
2
3
4
MOUTH/THROAT
Sore Throat
0
1
2
3
4
Swollen Throat
0
1
2
3
4
Swelling of Lips/Tongue
0
1
2
3
4
Gagging or Throat “Clearing”
0
1
2
3
4
Lesions (“Canker Sores”)
0
1
2
3
4
WEIGHT MANAGEMENT
Overweight
0
1
2
3
4
Fluctuating Weight
0
1
2
3
4
Food Cravings
0
1
2
3
4
Water Retention
0
1
2
3
4
Binge Eating or Drinking
0
1
2
3
4
Purging (all methods)
0
1
2
3
4
CAPTCHA
Name
This field is for validation purposes and should be left unchanged.
Δ
CLOSE
