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Substance and Diet Intake Form
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* Indicates required question
Name
*
Your answer
Are you currently taking any prescription medicines or have you taken any in the past year?
*
Your answer
What are the diagnoses associated with each medicine?
Your answer
Please list any over the counter medicines that you have taken in the past year, the symptoms which you were treating and the frequency of usage:
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Your answer
Please list any vitamins, herbs, or supplements you have taken in the past year, the symptoms which they were treating and the frequency of usage:
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Your answer
Which of the following do you use?
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Never
Occaisonally
A couple times a year
Once a month
Multiple times a month
Weekly
Multiple times a week
Daily
Coffee
Tea
Soft Drinks
Diet Soft Drinks
Artificial Sweetener
Anatacids
Laxatives
Candy
Ice Cream
Alcohol
Cigarettes
Other Tobacco Products
Never
Occaisonally
A couple times a year
Once a month
Multiple times a month
Weekly
Multiple times a week
Daily
Coffee
Tea
Soft Drinks
Diet Soft Drinks
Artificial Sweetener
Anatacids
Laxatives
Candy
Ice Cream
Alcohol
Cigarettes
Other Tobacco Products
How many desserts do you average a week?
*
Your answer
How is your appetite?
*
Low
Average
High
Please describe your typical breakfast:
*
Your answer
Please describe your typical lunch:
*
Your answer
Please describe your typical dinner:
*
Your answer
How much water do you drink on a daily basis?
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Less than a glass a day
At least one glass a day
Multiple glasses a day
I don't know
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