Complimentary Patient Prescreening

Technology has become such a vital component to the medical field

If you think you may have food sensitivities and:

• You are not currently working with a healthcare provider who offers MRT testing and the LEAP Protocol
• You are interested in working directly with Oxford Biomedical Technologies

Please complete and submit the Patient Prescreening Form below. After submission, an Oxford representative will review your information and contact you to discuss whether food sensitivities may be contributing to your health concerns and whether MRT testing may be appropriate.

Important: If you are currently working with a healthcare provider who will be ordering your MRT test, please do NOT complete the Prescreening Form. Your healthcare provider should coordinate the testing process with you directly.

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

LUNGS

EMOTIONAL/MENTAL SYMPTOMS

EYES

GENITOURINARY

HEAD/EARS

MUSCULOSKELETAL

SKIN

CARDIOVASCULAR

NASAL/SINUS

DIGESTIVE

MOUTH/THROAT

WEIGHT MANAGEMENT