| 1. |
How many meals (including snacks) do you eat daily? |
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| 2. |
Do you drink liquids: |
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| 3. |
Do you eat gas-forming foods (e.g. cabbage, cauliflower, broccoli, dried beans; gassy cold drinks): |
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| 4. |
Do you usually drink alcohol: |
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| 5. |
Do you drink tea, coffee, cola beverages, chocolate, cocoa or other caffeine-containing beverages: |
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| 6. |
Do you eat spicy foods (including chilli, curry, cured or smoked food, pickles, vinegar etc.): |
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| 7. |
Do you eat fried and fatty foods (including take-aways): |
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| 8. |
Do you chew gum? |
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| 9. |
Do you lie down within 2 hours after eating? |
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| 10. |
Do you smoke? |
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| 11. |
Are most of your meals eaten when in a hurry? |
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| 12. |
Do you eat peppermints: |
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