If you have any questions, please do not hesitate to contact your TELUS Health Care Centre.
Food intolerances/allergies and dietary restrictions
Please list any dietary restrictions that you have (foods/beverages that you avoid):
Areas related to nutrition goals and interests
Diabetes/blood sugar management
Blood pressure management
Trending diet/special dietary patterns
Diet and inﬂammation
Meal planning and ideas
Improving my relationship with food
Other digestive concerns (tell us more):
Other (tell us more):
Supplements (vitamins, minerals, herbal products, protein powders)
Make sure to note the amounts that you take and product brands:
Juice or soda cups/day
Energy drinks times/week
Red meat times/week
Milk/milk alt. cups/day
Fruits and vegetables
Sweets /treats times/week
Salty snacks times/week
Do you include legumes (i.e., beans, lentils, etc.)?
Weekly Sometimes Never
Do you include nuts and/or seeds? Daily Sometimes Never
Do you choose whole grain products (i.e., bread)? Mostly Sometimes Never
What cooking oils/fat do you use?
How often do you dine out/get take-out weekly?
First and last name: