Please use the + button to add rows as needed for each additional child.
Please list your known Medical Conditions (e.g., high blood pressure, diabetes, elevated blood sugar, cholesterol, high LDL, low HDL, elevated liver enzymes, cancer, food allergies or sensitivities etc.) — Use the + button to add additional rows as needed (up to 15) — This information will be kept confidential!
Describe how you normally eat. Check the boxes for all that apply.
Please name which programs or eating styles you have tried and the results you have achieved. For example: lost weight, medical changes, sleep, energy, mental clarity, cravings, or other.