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Health Services of Carmel

Phone: 831-262-9799 * Fax: 831-763-9251

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Diet Information for [name]______________________________________________________

Some people eat diets that are just on the run, grab what you can, others eat diets that they learn to

be healthy choices, not all eat balanced diets. Sometimes people think they are doing the right

choices, but the combinations could be causing uncomfortable situations. We ask for the information

below to see if we can suggest a few changes to correct imbalances. Sometimes small changes can

make huge differences. The more you write, the more we can help.

What percentage of your meals are Microwaved?______ Fried?_____________

Baked & Steamed?__________ Fresh/Uncooked?____________

Give a basic description of your diet in general : Are you a Vegetarian?________________________

Do you eat out in restaurants alot?________________Fish/ Suishi Restraurants?________________

Do you eat more carbohydrates, more proteins, more processed foods?_____________________

What percentage of potatoes do you eat?______________ Bread?___________________

What percentage of sugary deserts, __________________ Junk Food?__________________

Soft Drinks? ____________________ How much water do you drink in a day?_____________________

This part of the chart is important. Try to be as accurate as possible.

Do you drink coffee, tea, juice, etc._______________________________________________________

Please list what type of breakfast you eat in a 3 day period____________________________________

____________________________________________________________________________________

Please list what type of lunch you eat in a 3 day period ____________________________________

____________________________________________________________________________________

Please list what type of dinner you eat in a 3 day period ____________________________________

____________________________________________________________________________________

Please list what type of desert or snack foods you eat in a 3 day period __________________________

____________________________________________________________________________________

List any other information you feel is important; ______________________________________________

____________________________________________________________________________________

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Mail To: H.S. of Carmel, P.O. 1149, Carmel, CA 93921, Phone: 831-656-9771

Client Name:_____________________________ Phone#_______________

Address: ____________________________________________________________

__________________________________________________________________

Referred By: ____________________________

Date of Birth: __________ Sex M /F

Occupation: ______________________________________________

Any weight problems {trouble loosing or gaining]? Y/N _____________________________

List if currently taking any prescription drugs / Supplements/ Vitamins/ Over the counter Drugs, Shots. Use back of paper if needed

Do you have Mercury amalgam fillings? Y/N Do you take Pain Killers?______________

Do you have a water softener? ____________ Do you have Tattoos?______________

Have you had any trauma, accidents, artificial equipment or chronic issues? Y/N

Explain:________________________________________________________________________

_______________________________________________________________________________

Headaches: Y/N Sinus Issues: Y/N What sleeping aids do you take? _______________

Acid Reflux: Y/N Hair Skin Issues: Y/N Emotions: Y/N Heart Issues: Y/N

Blood Pressure issues: Y/N Stomach/Digestive Issues: Y/N Constipation: Y/N

Muscle/ Skeletal Pains: Y/N Male/ Female Problems: Y/N

Any respiratory Issues? Explain:_________________________________________________________________

What Essential Oils do you use? _____________________________________________

Health problems or concerns: _____________________________________________________________________________

_____________________________________________________________________________