Complimentary Patient Prescreening

Technology has become such a vital component to the medical field

If you think you might have food sensitivities, are not currently working with a healthcare provider that offers LEAP, and are interested in working directly with Oxford, please fill in the information in the Prescreening form below. This will start the process of determining the likelihood that food sensitivities are playing a role in your health problems.

Note: If you are currently working with a Healthcare provider to order an MRT test please DO NOT complete the Prescreening form.

Company

Lead Type

Lead Source

Lead Stage

Last Name*

How did you first hear about MRT?

First Name*

Middle Initial

Last Name*

Street*

City*

State*

Zip Code*

Country*

Best Phone*

Mobile

Fax

Email*

Male/Female*

Date Of Birth

Height (Inches)

Weight (lbs)

Is There A History of Allergies in your Family?

What are your main health complaints (In Order of Importance)

List All Medications (Prescription & OTC) Currently Taken on Regular or as Needed Basis

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)

Hyperactive (nervous energy)

Restless (can’t relax/sit still)

Sleepiness during day

Insomnia at night

Malaise (feel lousy)

LUNGS

“Wheezing” (Asthma/ Asthma-Like Symptoms)

Chest Congestion

“Non-Productive” Coughing

“Productive” Coughing

EMOTIONAL/MENTAL SYMPTOMS

Depression (feelings of hopelessness)

Anxiety (vague fears, uneasiness)

Mood Swings (rapid, distinct changes)

Irritability (anger, hostility)

Forgetfulness

Lack of Concentration/Focus

EYES

Red or Swollen Eyes

Watery Eyes

Itchy Eyes

“Dark Circles” or “Baggy” Eyes

GENITOURINARY

Increased Urinary Frequency

Painful Urination

HEAD/EARS

Headache (any kind)

Earache

Ear Infection

Ringing in Ear

Itchy Ears

Discharge from Ear

MUSCULOSKELETAL

Joint Pains/Aching

Stiff Joints

Muscle Aches

Stiff Muscles

Arthritis (Diagnosed)

SKIN

Skin Blemishes, Acne

Rashes, Hives

Eczema

“Rosy” Cheeks

CARDIOVASCULAR

Irregular Heartbeat

High Blood Pressure (Diagnosed)

NASAL/SINUS

Post Nasal Drip

Sinus Pain

Runny Nose

Stuffy Nose

Sneezing

DIGESTIVE

Heartburn/Esoph. Reflux

Stomach Pains/Cramps

Intestinal Pains/Cramps

Constipation

Diarrhea

Bloating Sensation

Gas (of Any Kind)

Nausea, Vomiting

Painful Elimination

MOUTH/THROAT

Sore Throat

Swollen Throat

Swelling of Lips/Tongue

Gagging or Throat “Clearing”

Lesions (“Canker Sores”)

WEIGHT MANAGEMENT

Overweight

Fluctuating Weight

Food Cravings

Water Retention

Binge Eating or Drinking

Purging (all methods)

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