Ketogenic Diet Patient Intake Form
“Let food be thy medicine. And medicine by thy food!” Hippocrates (3-58BC)
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
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Weekly Hours worked
Work Environment (eg. City, Office Building, Agricultural, Rural, Delivery, etc.)
How many years have you had this occupation?
Do you have children? If yes, please list how many and their ages below.
Briefly, describe why you think the keto lifestyle may be for you?
What are you hoping to achieve? Picture yourself 3 to 6 months from now. Where do you want to be?
What concerns do you have?
Do you feel yourspouse/family/friends will support you through your keto experience, explain?
Please list all your health issues/concerns below (high bloodpressure, low thyroid, fatigue, etc.)
Medications & dosages including all vitamins and supplements and why you are taking them (important):
Allergies/side effects to medications (please list them and the side effect associated with them:
Have you had any recent blood work and/or medical tests and what were the results:
List any major surgeries and/or biopsies you have had? Dates?
What do you want to change regarding your health history? Where do you see yourself with your health in one year? What are you willing to sacrifice to regain your health?
Please indicate on the chart below and the listed diseases and conditions that a family member may have had or has. Leave blank those that do not apply.
High Blood Pressure
Is anyone in your family overweight or obese? Please explain how this has affected you and if you think it may have contributed to their medical conditions:
What is your Height?
How much do you weigh today?
Is your current weight stable?
Has your primary physician recommended you need to lose weight? If Yes how much?
If you have dieted in the past, which programs have you tried? Did they work?
Which body image best describes you? Please put the number under the image in the box.
Is your blood pressure within the normal range? What does it normally run?
What is your resting heart rate? Beats per minute.
Have you been told you suffer from high cholesterol? What are your last LDL/HDL numbers?
If you have been told your cholesterol is too high, has your doctor recommended a statin drug?
Have you been told you are pre-diabetic or insulin resistant?
Have you been told you are diabetic? Do you know your A1C?
If you are diabetic, do you keep track of your glucose levels at home? What does your glucose normally run?
Your Daily Lifestyle
Do you enjoy your life and what does that mean? Expand on that.
Do you have others in your family/friendship circle that depend upon you for emotional/physical support and how does it make you feel?
Have there been any recent changes in your lifestyle that concern you? (marriage, divorce, death, move, new job, etc.)
Do you work long or irregular hours and what are they?
Do you like your job and/or take pride in your work achievements? Please expand on that.
Do you feel that you are stressed out? What do you do to cope? Meditation? Physical Exercise? Explain.
Do you exercise? ____Yes _____No If Yes, please expand on the frequency, duration and what type of exercise you do each week.
Do you take time for yourself or do you feel guilty when you are relaxing? Please expand on that.
Do you consider yourself a “go getter” or a more “go with the flow” kind of person? Why?
Do you have any hobbies and what are those?
Do you sleep well, or have insomnia? Please describe your sleep patterns.
Doyou have an active social life? Attend family get gatherings? Feel that you arepart of the community? Church? Explain.
Are you the major meal preparer in your family circle?
How often do you eat dinner at home with your family?
How often do you eat fast food because you don’t have time to cook?
Do you take vacations or little get aways? How often and where?
Do travel for work? How often and where?
Your Digestive Health
Please describe your bowel movements. Are the soft or hard? How often do you go? Do you ever see blood or mucus in your bowel movements? Do you need a laxative to go?
Do you suffer from stomach aches, IBS, diarrhea? How often? Do you take medications and which ones?
Have you ever had gall bladder issues or had your gallbladder removed?
Do you drink alcohol? How much and how often?
What kind of fluids do you drink throughout the day? How much?
Have you had a colonoscopy? What were the results?
Do you eat organic food? Is so, which kinds? Vegetables? Meat?
Do you eat oily fish like salmon? If so, how often?
Do you consume artificial sweetners?
Do you drink sugary sodas or other liquids? How often per day?
Do certain foods bother your? Which ones?
Have you been diagnosed with food allergies? If yes, which foods and what do they do?
How many servings a day do you consume of breads, pastas or rice?
How many green leaf vegetables do you consume daily?
How many servings of fruit do you have daily?
How many servings of protein like fish, meat or eggs do you eat daily?
How many sweet desserts do you eat daily or weekly?
Do you get irritable or dizzy if you don't eat often?
Are there certain foods or food groups you can not consume do to religious beliefs or moral beliefs?
What are your favorite foods?
What foods do you dislike?
Do you use caffeine, sugar or nicotine to keep going when you feel fatigued? Please explain:
Do you ever binge eat? Explain what you think is the cause?
Have you ever suffered from an eating disorder like bulimia or anorexia nervosa?
Do you eat to live? Or live to eat? Explain:
Pre-Menopausal Women Only
Are you pregnant?
Are you trying to get pregnant?
When was your last period? How long did it last?
How many children have you had? How many still live at home?
Have you ever had polycistic ovarion disease or POS? Explain and any treatment you may have had?
Do you get frequent urinary tract infections or have problems with yeast infections?
Do you suffer from bloating, irritability, fatigue, headaches, etc. during your period or rightbefore? Explain.
Do the above symptoms go away once your period is over?
Post-Menopausal Women Only
How many years ago did you have your last period?
Did you or do you now experience hot flashes, vaginal dryness or lack of sex drive? Explain:
Are you taking any hormone replacement medications? If Yes, What kind etc. Please explain:
Have you had a hysterectomy? Do you have your ovaries?
Have you gained weight as a result of going through menopause? Please explain your experience:
For Men Only
Do you experience mood swings, anxiety or depression? If yes, please explain.
Do you have any fertility problems?
Do you have difficulty urinating and fully emptying your bladder?
Doyou have any known prostrate problems?
Whenwas your last PSA test and was it normal?
Do you have pain or burning with urination?
Are you on hormone replacement therapy/Testosterone? Explain.
Do you suffer from feelings of fatigue?
Do you think you have lost muscle mass? Gained fat around your mid-section as you’ve aged? Explain:
Are you experiencing mood swings, depression and anxiety? Explain.
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