Health History & 7 Day Food Log

Please be sure you follow these steps to insure that your Health History Form gets completed and submitted properly.

  1. Keep your 7-day food log separate and enter it into this form all at once. If you close out of your browser, any information you enter will be lost.
  2. Be sure to fill out the “Captcha” at the end of the form. If you don’t, you will be notified to do so.
  3. After you hit “send”, you should see a green confirmation message. You should also get a confirmation email. If you don’t – please contact prior to your consultation.

Please complete and return this form no later than 24 hours prior to your consult. We would prefer this form completed ONE WEEK prior to your consult.

First and Last Name

Date of Consultation

Street Address

City: State/Province: Zip:

Your Email

Phone Number

Date of Birth


Current Weight

Goal Weight


Are you pregnant? YesNo

Are you nursing? YesNo

Do you have diverticulitis? YesNo

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

What is your current exercise program? Include #days/wk, intensity, duration each time.
Example "Jog a 5k, 11 minute miles, 3 days a week"

Any additional information you would like to include

Choose your Practitioner from the menu: