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: _____________________________________________________________________________
_____________________________________________________________________________
