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 *
Include date of diagnosis and type of cancer . Also include stage and grade if known.
How did you learn about the ketogenic diet for cancer? *
Check all that apply
What method of contact do you prefer for a consultation? *
Weekends included
City and country
List names, ages, and relationship.
Has your weight changed recently? *
Include dates and outcomes of surgery, chemo, radiation. Also include metabolic therapies, such as IV vitamin C and hyperbaric oxygen.
e.g. fatigue, speech, cognition, motor, endocrine
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
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 non-food allergies or sensitivities? *
e.g. latex, seasonal, environmental, chemical
Do you currently have any difficulty with appetite, chewing, swallowing, or digestion? *
e.g. constipation, nausea, reflux, Crohn’s, IBS, dental problems
Have you ever been treated for liver, kidney, gallbladder, or pancreatic disease? *
Do you drink coffee or tea? *
Caffeinated? Caffeine free?
Do you drink alcohol? *
Type, duration, intensity, and days per week.
e.g. meditation, yoga, prayer, bodywork, acupuncture, humor, the Arts, socializing, reading
How does stress affect your desire to eat?
e.g. restful or restless; difficulty falling asleep; difficulty staying asleep
e.g. timing of meals/snacks; timing of exercise; work hours
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?
e.g. prolonged nightly fasting, time restricted eating, water-only fasts
What are your favorite keto-friendly non-starchy vegetables? *
Check all that apply.
e.g. garlic, onion, tomatoes, mushrooms
Do you eat berries?
If so, what kinds?
If so, what kinds?
Include 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.
e.g. butter, ghee, heavy whipping cream, sour cream
If not, why not?
Check all that apply
e.g. olive, coconut, avocado, flaxseed, salad dressings, mayo
Do you enjoy nuts, nut butters, and seeds? *
(FYI: Juicing is generally not recommended in keto for cancer)
e.g. water, coffee, tea, almond milk, coconut milk
Do you enjoy avocados and olives? *
Are you currently using any of these ketone supplements?
Do you have any food allergies, aversions, or intolerances? *
e.g. casein, lactose, eggs, nuts, histamine
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?
Are you currently using apps or other tools for meal planning or tracking? *
I have read the Terms and Conditions *
Checking a box below indicates that you have read and accepted the Terms on the Support page.
Descriptions of both Consultations are on my website Support page.