I. NAME SYMPTOMS OR PROBLEMS THAT YOU BELIEVE ARE RELATED TO PKU.

   A.

   B.

   C.

II. DO YOU BELIEVE THAT GOING BACK ON DIET CAN HELP YOU FEEL BETTER OR
    SOLVE THE PROBLEMS LISTED ABOVE? ANSWER YES OR NO FOR EACH OF THE
    SYMPTOMS OR PROBLEMS LISTED ABOVE.

    A. YES NO

    B. YES NO

    C. YES NO

III. NAME PEOPLE IN YOUR LIFE THAT CAN HELP YOU WITH YOUR RETURN TO DIET.

    A.

    B.

    C.

IV. HOW WELL DO YOU THINK YOU CAN MANAGE THE DIET? THINK ABOUT THE FOLLOWING:

A. PAYING FOR THE DIET (INCLUDING LOW PROTEIN FOODS AND THE MEDICAL BEVERAGE -- FORMULA)

B. ORDERING/GETTING THE MEDICAL BEVERAGE AND THE LOW PROTEIN FOODS

C. PREPARING THE MEDICAL BEVERAGE

D. PLANNING MEALS

E. COOKING MEALS

F. FOOD SHOPPING

G. TOLERATING THE MEDICAL BEVERAGE (TASTE AND SMELL)

H. FEELING HUNGRY

I. STORING THE FOODS

J. KEEPING TRACK OF WHAT YOU EAT (FOOD RECORDS)

K. COUNTING PHE LEVELS

L. TAKING BLOOD SAMPLES

M. GOING OUT TO EAT

N. TRAVELING AWAY FROM HOME

O. TELLING FRIENDS AND CO-WORKERS ABOUT THE DIET

E-MAIL ADDRESS :

REMEMBER: YOU NEED SAM FOR THE DIET TO BE SUCCESSFUL --

SOCIAL SUPPORT, POSITIVE ATTITUDES, AND MANAGEABILITY

Completed form is being sent to the New England Consortium of Metabolic Programs