First and Last Name
Date of Consultation
City: State/Province: Zip:
Date of Birth
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
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.
Any additional information you would like to include
Choose your nutritionist from the menu:
Lyn-Genet RecitasDr. Katie ReinholtzCindy Hwang
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