Tips for completing an accurate Food Record >>
Food Intake Record >>
HIPAA Notice of Privacy Practices >>
Client Registration Adult >>
Client Registration Child >>
We request that you keep a log of your food intake for at least three days prior to your first visit, and then ongoing throughout your work with us. You may submit your food log by web, fax or email (instructions below):
1. Download and print this form >>
2. Complete the food log.
3. Fax to (818) 501-1543
To EMAIL us your food log:
1. Download this form >>
2. Complete the form electronically and save it to your personal computer (if you do not save to your computer, the information you entered will be lost)
3. Email your food log as an attachment to firstname.lastname@example.org
To submit your food log via the WEB:
Please fill in all the fields within the form below and hit the submit button. Once you hit the submit button you should see a confirmation that we have received your submission.