CLIENT INTAKE FORM

Client Checklist

Please complete and sign the HIPAA form, Office Policies, and Diet and Activity Logs. You can fax these to me, along with any lab results, to 415.520.0545.

Diet & Activity Log Instructions

Please don’t hesitate to reach out if you have any questions.

  1. Print out three copies and complete one each day for three days. Eat what you would normally eat and complete it as best you can.
  2. Write in the amount of food you eat, like “bowl of Cheerios‚ with a cup of milk and banana.” Among the measurements you may use are fluid ounce, ounce-weight, cup, gram, teaspoon (jam, butter), slice (bread), tablespoon, gallon, liter, or milliliters. If you list something as a “cup” (as in coffee or tea), a “glass” (milk, beer, water, etc.), or a “bottle” or “can,” estimate the size of the container. You may also write in just the quantity of the food when the amount is obvious, like “1 hamburger, 2 apples, 3 cookies”, or a “serving of McDonald’s fries” (but write in whether it was a small or large order).
  3. And finally, write in the contents of foods where appropriate. For example, instead of writing “vegetable soup”, write in “soup with carrots, vegetable broth, onion, garlic, etc.”
  4. Include any symptoms or abnormalities after eating such as diarrhea, excessive quantity of urination, racing heart, headaches, fatigue, irritability, runny nose, etc.
These intake questions will take about 15-30 minutes to complete. Please be as detailed as possible in your answers.

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