Health Questionnaire Form: 

To maximize our time together, please fill out the questionnaire below (click open questionnaire) before we meet.  This will allow me to review your health history, concerns as well as your submitted food journal so that I can provide you with specific recommendations at our first appointment. 

Food Journal

The food journal is an important tool in helping me discover what you are doing well and what we may need to change in order to bring your body back in to balance. 


FOOD Write down the types of foods you eat at each meal. Record ANYTHING and EVERYTHING that passes over your lips each day. This includes snacks and the “little nibbles” you think are insignificant. Be as specific as possible! Include sauces, gravies, and condiments.

WRITE DOWN EVERY MORSEL Keep your food journal forms with you all day and write down everything you eat and/or drink, no matter how small or large the serving and transfer them to this online form or just use the online form from your phone. Even if you eat a small piece of candy, a whole bag or cookies, a handful of nuts/seeds, a soda, or juice, write down ANYTHING you consume.

RECORD ANY DIGESTIVE and/or MOOD CHANGES Many experience intestinal gas, bloating, belching and other digestive pangs after eating. I need to be informed of these digestive symptoms. Also, if you experience energy and/or mood changes after eating, this is a sign that you may be eating an imbalanced diet (i.e. too many carbohydrates, too little fat and protein).

RECORD BOWEL MOVEMENTS If we are eliminating too often, this can be a sign of food allergies/intolerances. If we are eliminating too slowly, this may be an indication of a sluggish digestive tract. Please record when you have a bowel movement each day and also include whether or not you see undigested food in your stools, and/or if your stools are poorly formed (flat, loose), and/or if your stools are light in color (yes, you should be looking at your stools). These are important elimination symptoms that are helpful to your practitioner.  

DO IT NOW Write down what you are eating and drinking immediately. Don’t depend on your memory at the end of the day to help you fill in the blanks. Record what you eat and drink throughout the day.

BE SPECIFIC If you eat a whole pizza, WRITE IT DOWN! Include what was on the pizza (dough, cheese, meat, veggies, etc., etc.) and also include what you ate with it (soda, salad, pasta, bread sticks, and so on). Please include the ounces of beverages and cup measurements of food (you don't actually have to measure, just estimate) as often as possible. For example, if you write down that you had a bottle of water, please state the ounces of water in that bottle. If you cook at home, please indicate what type of fat/oil you used (olive, coconut, butter). Include all foods cooked and eaten along with main meals, as well as beverages and dessert, if any.

TELL THE TRUTH You have nothing to gain by trying to look good or to please your practitioner when completing your food journal. I can be much more helpful to you if I know EXACTLY what you are consuming and/or craving. No one is judging you, so help me serve you better by being completely honest about your eating habits


Before we work together, this disclaimer must be filled out, signed, dated and returned to me via email or through regular mail. 

Download the Nutritional Therapy Informed Consent and Disclaimer