It’s helpful if I know a little bit about you before we speak. This information will remain confidential and can be deleted from my database at your request. 

Now the disclaimer: Miriam Kalamian and Dietary Therapies LLC do not provide medical advice, diagnosis or treatment. Nutritional consultation is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare providers regarding a medical condition. Never disregard professional medical advice or delay in seeking it. 

Name *
Name
Birthdate *
Birthdate
Gender *
US/Canada Phone
US/Canada Phone
What method of contact do you prefer? *
Weekends included
City and country
List names, ages, and relationship.
Has your weight changed recently? *
Include date of diagnosis and type of cancer . Also include stage and grade if known.
Include dates and outcomes of surgery, chemo, radiation. Also include metabolic therapies, such as IV vitamin C and hyperbaric oxygen.
For example: fatigue, speech, cognitive, motor, endocrine, etc.
Include approximate date of diagnosis for each condition.
Are there any notable highs or lows in your lab results? *
E.G. low blood counts, low sodium, elevated liver enzymes, low albumin, high potassium, etc.
Include names and affiliations
Include dosage and frequency.
Include approximate starting dates. Email your list if that is easier for you.
Do you have any allergies, aversions, or intolerances? *
For example: latex, ragweed, lactose, histamine, etc.
Do you currently have any difficulty with appetite or digestion? *
Have you ever been treated for liver, kidney, gallbladder, or pancreatic disease? *
Do you consume coffee or tea? *
Include any Bulletproof drinks with coconut oil, ghee, MCT
Have you regularly consumed alcohol? *
Type, duration, intensity, and days per week.
For example: meditation, yoga, prayer, bodywork, acupuncture, humor, the Arts, socializing, reading/journaling, etc.
How does stress affect your desire to eat?
How did you learn about the ketogenic diet for cancer? *
Check all that apply
Do you have any of these keto supplies on hand? *
Please check all that apply.
Include cookbooks and/or favorite online sites.
For example, ketogenic, whole food organic, paleo, standard, mediterranean, vegetarian, vegan
For example, "started keto 3 weeks ago" or "whole food organic for 15 yrs"
If so, tell me more! How did you feel? Why did you stop?
Include water-only, intermittent, prolonged nightly fasts/time restricted eating.
e.g. timing of meals/snacks/exercise/work.
What are your favorite keto-friendly non-starchy vegetables? *
Check all that apply.
E.G.garlic, onion, tomatoes
What are your favorite keto-friendly berries?
Check all that apply.
Includes meat, poultry, fish, dairy, eggs, protein powders
Do you choose beef or lamb at least 2-3 times a week? *
If not, why not?
Check all that apply.
EG butter, ghee, heavy whipping cream, sour cream, etc.
If not, why not?
Check all that apply
E.G. olive oil, coconut oil, flaxseed oil, salad dressings, mayo, MCT.
Do you enjoy nuts, nut butters, and seeds? *
E.G. water, coffee, tea, Bulletproof beverages, almond milk, etc.
Do you enjoy avocados and olives? *
Are you currently using any ketone supplements? *
Check all that apply.
Do you have any food allergies, aversions, or intolerances? *
Are you currently using apps or other tools for meal planning or tracking? *
How do you feel about meal prep? *
Check all that apply
Are you responsible for preparing meals for your family? *
If yes, will someone be helping you with food shopping and meal preparation? *
Is this mostly for business? Socializing? Time or energy constraints?
I have read the Terms and Conditions *
Checking a box below indicates that you have read and accepted the Terms on the Support page.