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
Phone
Phone
Do you use video conferencing? *
If yes, please provide your Skype or other video contact details.
Where do you currently live?
Birthdate *
Birthdate
Gender *
Has your weight changed recently? *
Please include date, cancer type, stage, and grade if known.
Please include dates and outcomes
For example: fatigue, neurological, cognitive, motor, endocrine, etc.
Please include approximate date of diagnosis.
Are there any notable highs or lows in your lab results? *
For example: low blood counts, low sodium, elevated liver enzymes, low albumin, high potassium, etc.
Please include dosage and frequency.
Please include approximate dates you started each.
Do you have any seasonal or systemic allergies or intolerances? *
For example: latex, ragweed, lactose, histamine, etc.
Do you currently have any difficulty with digestion? *
If yes, please explain. For example: constipation, nausea, reflux, Crohn’s, IBS, slow GI motility, GI surgery, etc.
Have you ever been treated for liver, kidney, gallbladder, or pancreatic disease? *
If yes, please note the date of diagnosis, type of treatment, and current status.
Do you consume caffeine? *
If yes, please note how much and what type.
Do you consume alcohol? *
Please describe the type, amount, and frequency of your past and present use of alcohol.
Type, duration, intensity, and days per week.
For example: meditation, yoga, prayer, bodywork, acupuncture, humor, the Arts, socializing, reading/journaling, etc.
Please list their names, ages, and relationship to you.
Do you have any of these keto supplies on hand? *
Please check all that apply.
Please note if this is a recent change. For example: organic, Standard, Mediterranean, vegetarian, Paleo, Ketogenic.
For example: carbs, protein, fat.
What are your favorite "keto-friendly" non-starchy vegetables? *
Please check all that apply.
Do you eat berries or fruits? *
If yes, which are your favorites?
For example: meat, poultry, fish, dairy, eggs, protein powders, etc.
For example: butter, ghee, heavy whipping cream, sour cream, etc.
For example: olive oil, coconut oil, flaxseed oil, salad dressings, mayo, etc.
Do you enjoy nuts and seeds? *
If yes, which ones?
Do you juice? *
*Juicing is not recommended on a ketogenic diet. If yes, please list the foods that you juice most often.
For example: water, coffee, tea, Bulletproof beverages, almond milk, etc.
Do you enjoy avocados and/or olives? *
Do you have any food allergies or intolerances? *
If yes, please describe. For example: lactose, histamine, nut allergy, casein, etc.
Do you have any food aversions? *
If yes, please list.
Are you currently using apps or other tools for meal planning or tracking? *
If yes, which ones?
Do you love to cook or is meal prep a chore? *
Are you responsible for preparing meals for your family? *
Will someone be helping you with food shopping and meal preparation? *
If yes, does that person live with you?
Is this mostly for business? Socializing? Time or energy constraints?
I have read the Terms and Conditions *
This indicates that you have read and accepted the Terms on the Support page.