What are generally the best days and times to contact you?
What is your time zone?
City and country
Where do you currently live?
Height and weight
Please include date, cancer type, stage, and grade if known.
Interventions and/or Therapies
Please include dates and outcomes
What (if any) clinical symptoms led to your diagnosis?
What symptoms or limitations do you currently have?
For example: fatigue, neurological, cognitive, motor, endocrine, etc.
Additional health conditions
Please include approximate date of diagnosis.
What professionals are on your healthcare team?
List any prescription and/or over-the-counter medications that you regularly take
Please include dosage and frequency.
List current vitamins, supplements and herbal remedies
Please include approximate dates you started each.
Describe your pre-diagnosis and current physical activity.
Type, duration, intensity, and days per week.
What health-promoting and stress reducing activities do you enjoy most?
For example: meditation, yoga, prayer, bodywork, acupuncture, humor, the Arts, socializing, reading/journaling, etc.
Who lives at home with you?
Please list their names, ages, and relationship to you.
What are your goals in adopting this diet?
How did you learn about the ketogenic diet?
Nlog or forum
What meal planning or recipe resources do you currently have on hand?
Briefly describe your current eating pattern.
Please note if this is a recent change. For example: organic, Standard, Mediterranean, vegetarian, Paleo, Ketogenic.
If you have already started a ketogenic diet, what are your macros? How did you determine them?
For example: carbs, protein, fat.
What are your preferred protein foods?
For example: meat, poultry, fish, dairy, eggs, protein powders, etc.
Do you currently eat high-fat dairy products?
For example: butter, ghee, heavy whipping cream, sour cream, etc.
What types of fats and oils do you currently use?
For example: olive oil, coconut oil, flaxseed oil, salad dressings, mayo, etc.
What beverages do you drink?
For example: water, coffee, tea, Bulletproof beverages, almond milk, etc.
What best describes your daily routine
I enjoy a lot of variety in foods and meals
I keep meals simple most days
How often do you dine out?
Is this mostly for business? Socializing? Time or energy constraints?
What do you see as your biggest challenges in adopting and/or continuing with a ketogenic diet?
Is there anything else you would like me to know?
If this form was completed by a caregiver, please state your name and relationship.