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Adult Pre Consultation Questionnaire
Michael Koski
2022-03-25T17:05:36+00:00
Pre-Consultation Questionnaire for Adults with Seizures
First Name *
Last Name *
Email *
Address *
Address *
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
District of Columbia
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone Number
Date of Birth *
Age *
Height
Weight
What is your goal for this consultation? *
The type and duration of your seizures
How frequently do you have seizures?
What medications are your currently on?
Have you ever tried a diet for seizures? If so which one?
How long have you had seizures?
Why are you looking into MAD? Has your doctor suggested it?
Are you already seeing a dietician?
Any other serious illnesses/hospitalizations/injuries?
Do you have any allergies or sensitivities? Please list:
Are you involved with any other therapies? Please list:
Do you take any supplements? Please list:
Will friends & family be supportive of a diet/lifestyle change?
What are your favorite foods?
What percentage of your food do you cook at home?
What are your current eating habits? Breakfast, Lunch & Dinner
Do you crave sugar, coffee, cigarettes, or have any addictions?
Other Field
Is there anything else you would like to share?
Submit
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