eternity Cindy and Ian Rawlinson Acupuncturists
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Name _____________________________ Date________________________

Food Questionnaire

In terms of Oriental Health, it is important to find foods you like that keep you in balance and healthy. They are generally the ones that will make you vital and energetic. In order to begin finding the foods that go well with you, it is helpful to list the foods you eat each day for 7 days. The list doesn't need to be exact and you can include on it at the end foods you may be avoiding, but really enjoy. We should look at the whole picture to make your plan an enjoyable and natural process rather than one of rigid discipline. Please also include the drinks that you take and the time you have each meal.
DAY 1: _____________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

DAY 2: __________________________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

DAY 3: _____________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

DAY 4: _____________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

DAY 5: __________________________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

DAY 6: _____________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

DAY 7: _____________

Breakfast_______________________________________________Time_______

Lunch__________________________________________________Time_______

Dinner__________________________________________________Time_______

Snacks taken during the day ___________________________________________

__________________________________________________________________

Please list any foods you like or dislike, and any food cravings you experience.

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Do you have any other questions regarding your diet?

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

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