The information you enter in
this form is completely confidential and is not shared with any
other source, unless requested in writing.
My Diet History(Required)
About Your Food - Appetite - Cravings & Sensitivities
List your most frequently
eaten foods: include 10
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
How would describe your appetite?
(additional information OK)
Check any food cravings
(more than one
choice is possible)
Additional information regarding food cravings:
Please check the foods you
have problems with
(more than one choice is possible)
List
additional foods that you have problems with in this area
Please list all of the symptoms you
experience with any of the above
food(s)
If you do not experience and adverse reactions from food, check the box.
I do not experience any symptoms with foods..
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Food Choices & Preparation
Please put a number in each of the
following boxes that indicates where your
food is prepared; the total must equal 100 per cent; Example: Home 70% -
Restaurant 10% - Fast food 20% - Vending machines 0% - Other 0%
Home
Restaurant:
Fast Food:
Vending Machines:
Other:
Total (Automatically updated
and must be 100%):
How are foods prepared/eaten? (more than one choice is possible)
What are foods prepared from? (more than one choice is possible)
How are meals eaten? (more
than one choice is possible)
What beverage do you have with meals?
(more than one choice is possible)
Please check any of the diets you have ever tried (more than one choice is
possible)
List all other diets you have tried in this space:
From the list of diets you checked above, which one was the most successful.
Describe the results you obtained from the diet. If you did not achieve a result,
describe any difficulties or frustrations you encountered.
Do you use margarine, butter or both?
What type of oils do you use in cooking and food preparation? (more than one
choice is possible)
Do you use whole grain bread, rice and pasta or those made from white flour?
How many times per week do you dine
out in a seven day period?
How many meals, on average do you
consume per day?
How many times do you snack during the day?
Have you ever fasted?
If yes, when and how long?
Describe your experience with the fast, if it was helpful or not and any problems you experienced
No
Yes
Have you ever been on any type of a cleanse or detoxification protocol? If yes, explain
what you did, why you did it, for how long and any results you noticed:
No
Yes
Information Regarding Height & Weight
Your current height:
Have you lost height? If yes, how much?
No
Yes
Your current weight:
Your ideal weight:
The most you have weighed
Weight I have lost or gained in last 3 months
Do you have a goal regarding weight?
No
Yes
Yes - Remain at current weight
This personal information will be saved into your MyHealth Record Profile. It will also
be used by your on-line doctor to make personalized recommendations. Your history
is also used to setup your free My Journal to make tracking your progress even
easier.
Alcohol, artificial sweeteners and sugar laden drinks and food have delitrous
effects on the body, and, if taken for a long period of time can result in
degenerative conditions such as hypoglycemia, diabetes, heart disease, kidney
problems and cancer.
Food cravings and sensitivities indicate the inability to neutralize foreign
proteins. These two systems are the digestive and immune systems. We can help you overcome
food and chemical hypersensitivities.
Schedule your first call for free and let us
guide you to a better state of health.
One of the most important factors in regaining your health naturally is knowing
what foods you should consume and how to prepare them.
In today's fast food society, it's all too easy to put off selecting good foods
for consumption. Over time the human body has to pay for the damage done.
We can guide you through the sometimes impossible chore of making lifestyle
changes so you can regain your health and prevent future disease.
Schedule your first call for free and let us
guide you to a better state of health.
Weight loss is big business but unfortunately, most diets are pure marketing hype that result in companies making a lot of money and the
consumer poorer.
At BecomeHealthyNow, we truly believe that there isn't a "quick fix" to weight
loss. It takes persistence and a trained professional to know where to start.
People gain weight for different reasons and a trained clinical nutritionist is
best suited to help you determine where to start. We offer comprehensive lab
testing for the digestive, hormonal and cardiovascular systems. These tests take
the guess work out of finding the true cause of your altered state of body
function. When it comes to weight loss, why guess why you can't lose weight?
Please
review this form to be sure you have answered
the appropriate items and that your answers are accurate. Thank you
for choosing BecomeHealthyNow.com. We look forward to
helping you achieve your your health goals.
Please Note:
You have already
completed this sub-section of the MyHealth Analysis questionnaire. Your
answers are recorded above for you to review. If any of the data in the
form is NOT correct and
you need to CHANGE your answers, click the appropriate button
below. You
will then be allowed to make any necessary changes.
Please Note This Section is Complete:
You have already
completed this entire section of the MyHealth Analysis questionnaire. Your
answers are recorded above for you to review. If any of the data in this
subsection or any other subsection is NOT correct and
you need to CHANGE your answers, call your
on-line doctor, {doc_name} at {doc_phone}. He will make this entire
section incomplete and you will be able to make changes to any
sub-section. Your previous answers will NOT be lost, and you will be
able to review each sub-section and make changes.
Required)
