Am I Contributing to My Inflammation (Gout, Arthritis, Diabetes, etc.)?

Simply fill out and we will assess your situation and make suggestions to help you meet your Gout Free goals. The more detail you provide, the better we can help.

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What does your daily diet consist of? Please be as detailed as possible including all meals, snacks, and beverages.

How many ounces of water do you consume each day?

What is the source of your water?

Tap
Filtered
Distilled
Bottled

List any vitamins and/or supplements you take daily:

Please list any medications you take each day:

Are you overweight?

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No

Do you often deal with a lot of stress?

Have you been prescribed any antibiotics within the last 6-8 months?

Do you have any problems with urination or bowel movement frequency?

Gout/Arthritis/Joint Pain/Inflammation History: List how many years you have suffered, the severity of your attacks, and the frequency:

What is your current pain status and attack location?

Do you consume alcohol? If so what kind and how often:

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