entry date: exit · 2018-10-25 · ☐entry ☐exit . did you have citrus fillit or citrus juice...

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Page 1: Entry Date: Exit · 2018-10-25 · ☐Entry ☐Exit . Did you have citrus fillit or citrus juice during the past week? no Do you drink fillit drinks, sport drinks or punch? O no O

Date: ________________________________________

☐Entry

☐Exit

Page 2: Entry Date: Exit · 2018-10-25 · ☐Entry ☐Exit . Did you have citrus fillit or citrus juice during the past week? no Do you drink fillit drinks, sport drinks or punch? O no O

Page 3: Entry Date: Exit · 2018-10-25 · ☐Entry ☐Exit . Did you have citrus fillit or citrus juice during the past week? no Do you drink fillit drinks, sport drinks or punch? O no O

Page 4: Entry Date: Exit · 2018-10-25 · ☐Entry ☐Exit . Did you have citrus fillit or citrus juice during the past week? no Do you drink fillit drinks, sport drinks or punch? O no O

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