YEH CENTER OF NATURAL MEDICINE, INC.

195 North Second Avenue

Upland, California 91786

Phone: (909) 946-6444   Fax: (909) 946-1099

 

PERSONALIZED FOOD CONSULTATION - FORM B
First Name:   Middle Initial:  Last Name:
 
Email:
 
EATING PATTERN
 
How would you rate your appetite?  Good    Fair    Poor
 
How many meals do you eat each day?
 
How many times do you snack each day?
 
Do you have strong support and sufficient help from your family members and friends to maintain good health and proper diet? Yes    No
   
Please select the times when you eat daily meals (Please select all that apply)
12 a.m. 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m.
6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m.
12 p.m. 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m.
6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m.
           
Please select the times when you normally snack (Please select all that apply)
12 a.m. 1 a.m. 2 a.m. 3 a.m. 4 a.m. 5 a.m.
6 a.m. 7 a.m. 8 a.m. 9 a.m. 10 a.m. 11 a.m.
12 p.m. 1 p.m. 2 p.m. 3 p.m. 4 p.m. 5 p.m.
6 p.m. 7 p.m. 8 p.m. 9 p.m. 10 p.m. 11 p.m.
           
Do you keep this consistent pattern of eating? Yes    No
If no, please explain:
   
SPECIAL DIETS  
   
Are you on a special diet? Yes    No
If yes, please explain:
   
Is anyone in your family (those living with you) on a special diet? Yes    No
If yes, please explain:
Does it affect your eating habits and/or diet?
   
Do you have difficulty eating? Yes    No
If yes, please explain:
   
Do you suffer from anorexia, bulimia, or compulsive eating? Yes    No
If yes, please explain and list foods:
   
Do you turn to food as a way of coping with stress and/or depression?  
Yes, always    Yes, sometimes    No, never  
If yes, please explain:
   
Do you suffer from food allergies? Yes    No
If yes, please explain and list foods:
   

SMOKING, DRINKING, DRUGS

  
   
Do you smoke cigarettes? Yes    No
If yes, please indicate frequency:
   
Do you drink alcohol? Yes    No
If yes, please indicate frequency:
   
Do you take "street drugs"? Yes    No
If yes, please indicate frequency:
     
CURRENT FOOD FREQUENCY CHECKLIST
Food Servings, Amount &
Frequency Per Day		 Preparation Method
Vegetables
 
 
 
     
Fruits
 
 
 
     
Animal Meats & Seafood
 
 
 
     
Grains & Small Seeds
 
 
 
     
Beans, Nuts & Large Seeds
 
 
 
     
Dairy Products
 
 
 
     
Water & Beverages
 
 
 
     
The information I have provided is true and accurate to the best of my knowledge. I understand that this information will be held in strict confidentiality between the medical staff at Yeh Center of Natural Medicine, Inc. and myself.
 
The purpose of "Personalized Food Consultation" is to familiarize the patient with food medicine, nutrition, and diet on an individualized basis. The manual does not make any health claims, and the information introduced does not take the place of physician's care, medical procedures, lab tests, or any necessary medication.
 
Yeh Center of Natural Medicine, Inc. also does not in any way encourage any person to try to heal themselves or to stop their current medical care and supervision, as all medical treatment requires the knowledge and skill of a trained professional. Due to the personalized nature of this food medicine program, long hours are spent putting it together. Therefore, there is no exchange or refund for this book. I have read and understand the above statements.
 

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