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* 1. Name:

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* 2. Date and place of birth

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* 3. Relationship Status: Single, Married, Divorced, Widowed, etc:

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* 4. Living arrangements- live alone or with (Please specify)

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* 5. Profession:

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* 6. What is your height in feet and inches? For example, if you are 5 feet and 4 inches, write 5’4”.

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* 7. What is your current weight in pounds?

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* 8. What type of cancer were you diagnosed with?

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* 9. How long ago were you diagnosed?

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* 10. Has anyone in your family, friends and others around you been diagnosed with this type of cancer?

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* 11. Have you seen a Physician/ Oncologist for this particular concern? Name and specialty of the Physician.

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* 12. Do you take any prescription medication OR have you been treated for this concern? How long? (Please specify what kind and the dose)

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* 13. Do you, or have you ever self-medicated? What medication?

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* 14. Does this condition pose a threat to your life? Or to the life of others around you? Explain in detail?

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* 15. Would you be able to share medical records related to the above issue with me?

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* 16. Have you ever had any genetic testing done? (Ex: 23 & me or others) Please specify.

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* 17. Do you have any other test results you can share with me? (ex: food allergies, immune markers, etc)

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* 18. On a scale of 1-5 how much do you think this condition affects the following (with 1 =VERY LITTLE and 5= EXTREMELY Seriously ):

  1 2 3 4 5
Ability to get out of bed easily and routinely
Ability to care for yourself, personal hygiene, daily routine care
Ability to work, do your job effectively
Ability to attend social events
Ability to have an intimate relationship
Ability to engage in LIGHT physical activity
Ability to engage in a MODERATE physical activity
Ability to engage in an INTENSE physical activity
Ability to sleep/ uninterrupted, peacefully and regularly
Ability to consume certain foods
Ability to consume certain beverages
Ability to consume certain Vitamins/ Supplements
Ability to consume certain medications
Ability to eliminate (regular bowel movements, urination)
Ability to have Children

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* 19. On a scale of 1-5 how would you rate the pain that this is causing you?

  1 2 3 4 5
Overall Pain
Targeted pain
Daily
Occasionally

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* 20. How often do you experience pain associated with this condition/concern?

  1 2 3 4 5
Weekly
Daily
Hourly
All the time- Never stops hurting
Never- I do not have any pain associated with this condition/concer

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* 21. Are you able to follow my recommendations and instructions to help you with this condition?

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* 22. If you are NOT able to follow my recommendations, do you have someone to help you?

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* 23. Who is your helper and can I communicate with them?

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* 24. How reliable/available is your helper?

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* 25. Are you committed to make some necessary lifestyle changes in order to improve or eliminate this condition?

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* 26. Are you comfortable talking about this with others? Or is this kept quiet from others including your family and close friends? Why?

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* 27. In general, how would you rate your overall health?

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* 28. In general, how would you rate your overall mental or emotional health?

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* 29. When was your last physical exam? results? Normal, concerns, please specify:

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* 30. Please provide information about your family

  Genetic Disorders Cancer Diabetes Cholesterol Blood Pressure Mental Health
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Father
Mother
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6

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* 31. Please provide information about your family

  Alcohol Consumption Tobacco (Cigarettes, Pipes etc) Tobacco (Chew, e-cigarettes)
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Father
Mother
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Sibling 5
Sibling 6

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* 32. Do you consume:

  Frequency Amount Daily when applicable Amount Weekly when applicable
Breakfast
Mid morning snack
Lunch
Afternoon snack
Dinner
Evening snack
Vegetables
Fruits
Red meat (Beef, Pork, Lamb, Buffalo, Venison, other wild game)
Poultry (Chicken, Turkey)
Fish (Salmon, Cod, Haddock etc)
Shellfish (Shrimp, Lobster, etc)
Dairy (All milk-based such as milk, cream, cheese etc)
Eggs (Whole and Whites only)
Nuts (Almonds, Walnuts, Pistachios, Peanuts, Cashews etc)
Seeds (Flax, Sesame, Chia, Hemp, etc)
Soy based products (Tofu, soy milk, Tempe etc)
Grains and grain containing products (Bread, rolls, cereals, pasta, crackers etc)
Baked goods, pastries and sweets (Cakes, cookies, danishes etc)
Plain Water (No bubbles, flavors)
Juice
Coffee (caffeinated)
Coffee (Decaf)
Tea (Caffeinated)
Tea (Herbal, Caffeine-free)
Alcoholic beverages

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* 33. Please list any nutritional supplements you are currently taking.

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* 34. Do you have a regular bedtime and waking time? (Please specify)

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* 35. Do you sleep in on weekends?

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* 36. Your Sleep Pattern

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* 37. Have you or do you ever take sleeping aid (prescription or over the counter)?

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* 38. Please define your goals?

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* 39. In the space provided, please provide a food log for the last 3 days

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* 40. SPECIFICALLY what would you like me to do for you immediately?

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* 41. Do you know your

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