INTAKE FORMS

This form helps me understand your past and current health status.

Intake Form:

This form gives me a lengthy, but necessary picture of your current health, as well as your health history, please be thorough and fill out the appropriate sections.

Food Journal:

Please print seven copies and give a detailed description of what you eat. Please be very specific when inputting food choices.  You will also be asked to include the beverages you consume, any medications or supplements you may take, your daily exercise and your bowel movements.

It is my hope that this food journal will be completed thoroughly and thoughtfully so that it provides the vital information needed to meet any possible nutrition challenges head-on. There is no judgment here and no bad food choices. 

Personal Observations Form:

This is a questionnaire that will help you reflect on the feelings and energy levels that are created when you eat certain foods. Please use the questions on the top of the personal observations form as a guideline. You do not have to answer these daily, but rather you may want to make notes on the back of your food journal when you have ideas and take time at the end of the week to synthesize those notes into a synopsis of your overall feelings and any things you may have learned through the experience of doing the food journal. This will help guide you as you progress and begin to make nutritional changes.

Disclaimer Form

Please fill out this form before our first appointment.