Discuss With Your Doctor (S.T.O.P.)

Information is power. The more you can track your experience, the more information you have to use in identifying, managing, treating, and ultimately gaining control of your condition(s) and preventing future episodes. In Food Without Fear, Dr. Gupta presents an acronym—STOP—that will further help you arrive at solutions. Here’s a quick preview:

STOP sign graphic

In the book, Dr. Gupta presents a full understanding of food reactions and then you’ll have the information you need to chart your path to food freedom.

Directions: Answer as many of the following questions that apply to you (or a loved one who has a food-related concern) and bring this checklist with you to your/their doctor. Add additional notes where necessary. After you complete this form, it will export to a PDF that you can easily print.

These questions outline aspects of your/their medical history and experiences that are important for a health-care provider to consider when evaluating a food-related condition.

S.T.O.P. Questionnaire

What foods give you trouble?

List all, whether they are whole foods (e.g., peaches and eggs), whole categories of foods (e.g., dairy, shellfish), or single ingredients often mixed with other ingredients (e.g., gluten, sulfites, sugar). Please also include how often you experience symptoms:

Medical History

Check all that apply.

Family Medical History


Personal Medical History

Have you ever been diagnosed with any other health condition?
Do you take any medications, vitamins, or supplements, including those unrelated to any food condition?

Environmental History

Is there carpeting in this home?
Has there been water damage?
Are there any pets?


For each of those foods that you listed as causing you trouble:
What are your main symptoms? (check all that apply)
When you’ve had a reaction to this food, when did the reaction start?
Have you ever been tested or in any way evaluated for any food allergy or sensitivity/intolerance?*
* Be sure to bring any test results to your doctor’s
Have you ever tried a specific diet to treat your condition?
Have you tried any additional (non-dietary) therapies to control symptoms, including prescribed drugs or over-the-counter treatments?
Do certain activities or moments in your life seem to make your re- actions worse, such as exercise, drinking alcohol, certain medications, menstrual period, travel, periods of acute stress?
Let’s first gain a full understanding of food reactions and then you’ll have the information you need to chart your path to food freedom.