All of your information will remain confidential between you and me. PERSONAL INFORMATION First Name: Date: Last Name: Email: HEALTH INFORMATION What positive changes have you noticed since your last session?: What are your main concerns at this time?: Any changes with weight?: How is your sleep?: Constipation or diarrhea?: How is your mood?: FOOD INFORMATION Are you cooking more?: What foods do you crave?: What is your diet like these days?: Breakfast: Lunch: Dinner: Snacks: Liquids: ADDITIONAL COMMENTS Anything else you would like to share?:
