Adult Pre Consultation Questionnaire

First Name *
Last Name *

Email *

Address *

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?