Health History & 7 Day Food Log

Please complete and return this form no later than 24 hours prior to your consult.

First and Last Name

Date of Consultation
--

Street Address


City: State/Province: Zip:

Your Email

Phone Number

Date of Birth
--

Height

Weight

Are you pregnant?  Yes No

Are you nursing?  Yes No

Medications and supplements, please list:

Illnesses, hospitalizations, surgeries, please list:
If you have a serious illness or medical condition, we recommend you work with Lyn-Genet or one of our naturopathic doctors.

Please list any food allergies and seasonal/environmental allergies

Health Goals:

7-Day Food Log

Please complete this food log to include as much detail as possible. Remember to be as specific as you can with fruits and vegetables. Include beverage intake as well.

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Any additional information you would like to include

Choose your nutritionist from the menu:
Lyn-Genet RecitasDr. Katie ReinholtzCindy Hwang

Please enter CAPTCHA above.