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Forms & Food Records

Food Record >>
Tips for completing an accurate Food Record >>
Adult Nutrition Questionnaire >>
Teen Nutrition Questionnaire >>
Child Nutrition Questionnaire >>
HIPAA Notice of Privacy Practices >>

Food Records:
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 [email protected]

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.

Log Date:



The information contained in this website is not intended as a substitute for medical advice.
See your physician and/or Registered Dietitian for individual health and/or dietary concerns. Contact Us