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Name

Last name

Telefon

Address

Age

I have discovered food intolerance *

Yes

I have autoimmunity disorder *

Yes

I sometimes felt sick after tomatoes, fish, wine, yogurt or nuts *

Yes

Check your symptoms *

Diarrhea

Abdominal pain

Skin problem

Fatigue syndrome

Insomnia

Depression

Atopic eczema

Immunity problem

How long do I observe food-related symptoms?

I have eliminated Gluten in the past or now and health has not changed much *

Yes

I have excluded Lactose in the past or now and the health has not changed much *

Yes

I often have taste for sweet *

Yes

I have dietary restrictions, such as vegetarianism, veganism or a gluten-free diet *

Yes

I have used antibiotics in the last 3 months *

Yes

I want to have my child tested for food intolerances *

Yes

What test do I want

Synlab

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Note

s *

I agree to give the laboratory results to the nutritionist

I want to receive the latest health information

Děkujeme za zaslání. Náš tým se vám v co nejbližší době ozve.

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NutriClinics

info@nutriclinics.eu

tel: +420 722 062 846

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Synlab

I want to receive the latest health information

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