Include date of diagnosis and type of cancer . Also include stage and grade if known.
Are you in the US or Canada? If so, what is your Time Zone?
Atlantic (Canada only)
Phone Number (US/Canada only)
If "other", provide some detail here.
What are your best day/time options for a call?
Where do you currently live?
City and country
Who lives at home with you?
List names, ages, and relationship.
Height and weight
If so, approx how much have you gained/lost since your diagnosis ?
Interventions and/or Therapies
Include dates and outcomes of surgery, chemo, radiation. Also include metabolic therapies, such as IV vitamin C and hyperbaric oxygen.
What (if any) symptoms led to your diagnosis?
What symptoms or limitations do you currently have?
e.g. fatigue, speech, cognition, motor, endocrine
List any additional health conditions or concerns.
Include approximate date of diagnosis for each condition.
If so, list them here or forward a copy via email.
e.g. low blood counts, low sodium, elevated liver enzymes, low albumin, high potassium
What professionals are on your healthcare team?
Include names and affiliations
List any prescription and/or over-the-counter medications that you regularly take
Include dosage and frequency.
List current vitamins, supplements and herbal remedies
Include approximate starting dates. Email your list if that is easier for you.
If yes, list them below.
If yes, please provide some detail.
e.g. constipation, nausea, reflux, Crohn’s, IBS, dental problems
If yes, please note the date of diagnosis, type of treatment, and current status.
If yes, please note how much and what type.
Caffeinated? Caffeine free?
If yes, describe the type, amount, and frequency of your past and present use of alcohol.
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?
e.g. meditation, yoga, prayer, bodywork, acupuncture, humor, the Arts, socializing, reading
When do you go to bed? When do you get up?
Describe the rhythm of a typical day...
e.g. timing of meals/snacks; timing of exercise; work hours
What are your goals in adopting this diet?
What do you see as your biggest challenges in implementing a ketogenic diet?
What meal planning or recipe resources do you currently have on hand?
Include cookbooks and/or favorite online sites.
Briefly describe your current eating pattern.
For example, ketogenic, whole food organic, paleo, standard, mediterranean, vegetarian, vegan
How long have you followed this pattern?
For example, "started keto 3 weeks ago" or "whole food organic for 15 yrs"
Have you ever followed a low-carb plan before? (e.g. Atkins)
If so, tell me more! How did you feel? Why did you stop?
If you are already following a keto plan, what are your macros (carbs, protein, fat)?
Do you practice any type of fasting?
e.g. prolonged nightly fasting, time restricted eating, water-only fasts
Are there other favorites not on the list?
e.g. garlic, onion, tomatoes, mushrooms
Do you eat fruit?
If so, what kinds?
What are your preferred protein foods?
Include meat, poultry, fish, dairy, eggs, protein powders
Do you currently eat high-fat dairy products?
e.g. butter, ghee, heavy whipping cream, sour cream
What types of fats and oils do you use?
e.g. olive, coconut, avocado, flaxseed, salad dressings, mayo
If yes, which ones are your favorites?
If you "juice", list the foods that you include
(FYI: Juicing is generally not recommended in keto for cancer)
What beverages do you drink?
e.g. water, coffee, tea, almond milk, coconut milk
If yes, please describe.
e.g. casein, lactose, eggs, nuts, histamine
How often do you dine out?
Is this mostly for business? Socializing? Time or energy constraints?
Is there anything else you would like me to know?
Have you read my Keto for Cancer book?
If this form was completed by a caregiver, please state your name and relationship.