Food Dyes and Behavior Report Form

Do food dyes (or other ingredients) affect your child's behavior? If so, please fill out this report form.

Your Name	E-mail address
Name of affected person	Home Phone (area code/number)
Age of affected person 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99	Work Phone (area code/number/ext)
Address
City	State	ZIP

Describe problem caused by food dyes

Are the symptoms: Mild Moderate Severe

Describe how your child benefited from avoiding dyes:

What other ingredients/additives contribute to the problem, or are food dyes the main problem?

Has your or your child's doctor been helpful? Unhelpful? Please explain.

Would it make your life easier if the government required food manufacturers to switch to safer, natural colorings? Yes No

List any other food allergies or sensitivities that your child (or other person affected by dyes) has.

How did you hear about this website?

Do you belong to the Feingold Association (www.feingold.org)? Yes No

Thank you for submitting this adverse reaction report. The information you provided may be useful to health authorities in the United States, but your name and other contact information will be kept confidential.