The Low Nickel Diet

Intake Questionnaire

The Low Nickel Restart · by The Low Nickel Diet

This helps me understand where you're starting from so I can personalize your experience. No wrong answers — just be honest about where you are right now.

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Before We Begin

Please read and acknowledge the following:

I understand that this questionnaire is for nutritional coaching purposes only, does not create a doctor-patient relationship, and is not a substitute for medical care.
Section 1 of 6 ~8 min
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Section 1 of 6
About You
Let's start with the basics.
First name *
Email address *
How did you find me?
Select all that apply
YouTube
Instagram
Facebook
My cookbook
Google search
A friend / family
A doctor
Reddit
Other
🩺
Section 2 of 6
Your Symptoms
Tell me what you're experiencing right now.
Current symptoms *
Select all that apply
🫧 Dyshidrotic eczema
🔴 Eczema (other areas)
✋ Contact dermatitis
🫁 IBS / digestive issues
🎈 Bloating
🔥 GERD / heartburn
🤢 Nausea
😴 Chronic fatigue
🌫️ Brain fog
🤕 Headaches / migraines
🦴 Joint pain
🪲 Skin itching (no rash)
🟠 Hives / urticaria
👄 Mouth sores / burning
➕ Other
Symptom severity right now *
1
2
3
4
5
6
7
8
9
10
Barely noticeableSeverely impacts daily life
How long have you had these symptoms? *
Less than 6 months
6 months – 1 year
1–3 years
3–5 years
5–10 years
More than 10 years
Symptom pattern
Constant — always about the same
Cyclical — flare, improve, repeat
Seasonal — worse certain times of year
Unpredictable — no clear pattern
Anything that makes symptoms better or worse?
Optional — foods, stress, sleep, seasons, etc.
🧪
Section 3 of 6
Diagnosis & History
Understanding your background helps me personalize your approach.
Have you been patch tested for nickel? *
Yes — positive for nickel
Yes — positive for nickel AND other allergens
Yes — negative for nickel
No — but I suspect nickel allergy
No — I'm not sure if nickel is my issue
I don't know what patch testing is
If positive for other allergens, which ones?
Have you been diagnosed with any of these?
Select all that apply
IBS
Celiac disease
Gluten sensitivity
Histamine intolerance
MCAS
GERD
SIBO
Endometriosis
Fibromyalgia
Thyroid condition
Autoimmune condition
Anxiety / depression
None of the above
If you have IBS, which type?
IBS-C (constipation dominant)
IBS-D (diarrhea dominant)
IBS-M (mixed)
Not sure
I don't have IBS
Current medications
Optional — list anything you're currently prescribed
Current supplements
Important — many supplements have high nickel from fillers
🍽️
Section 4 of 6
Your Current Diet
No judgment — I just need to know your starting point.
What do you typically eat in a day? *
Just a rough idea — don't overthink it
Have you tried the low nickel diet before? *
No — completely new to me
Looked into it but haven't really tried
Tried it casually but not strictly
Tried it strictly but stopped
Currently following it to some degree
If you've tried it before, what happened?
Optional — did it help? What was hard? Why did you stop?
Dietary restrictions beyond nickel?
🥬 Vegetarian
🌱 Vegan
🥛 Dairy-free
🌾 Already GF
✡️ Kosher
☪️ Halal
⚠️ Food allergies
✅ None
Do you have the Low Nickel Diet Cookbook?
📖 Yes — I've read it
📕 Yes — haven't read it yet
🛒 No — plan to get it
No
🌿
Section 5 of 6
Your Lifestyle
These factors directly affect how your body handles nickel. Honest answers help me help you.
Hours of sleep per night *
Less than 5 hours
5–6 hours
6–7 hours
7–8 hours
8+ hours
Sleep quality *
1
2
3
4
5
6
7
8
9
10
Terrible, never restedExcellent, wake up refreshed
Current stress level *
1
2
3
4
5
6
7
8
9
10
Very low stressExtremely stressed
How often do you exercise?
Rarely or never
1–2 times per week
3–4 times per week
5+ times per week
Do you drink filtered water? 💧
Yes — heavy-metal filter (Berkey, RO, etc.)
Yes — basic filter (Brita, etc.)
Yes — bottled water
No — tap water
I'm not sure what filter I have
Cookware you primarily use 🍳
Select all that apply
Stainless steel
Cast iron
Non-stick / Teflon
Ceramic
Glass
Not sure
🎯
Section 6 of 6
Your Goals
Last section — tell me what success looks like for you.
Top 1–3 goals for this program *
e.g., "Clear my eczema," "Figure out which foods are safe," "Stop the IBS"
Commitment level *
How committed are you to following through for 12 weeks?
1
2
3
4
5
6
7
8
9
10
Not veryFully committed, all in
Biggest fear or concern about starting?
Anything else I should know?
✅
All done!
Review & Send
Here's a summary of your responses. Send it directly to Dr. Laura via email or copy to your clipboard.

Your Intake Summary

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Dr. Laura Duzett, DO NTP · thelownickeldiet.com · info@thelownickeldiet.com