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DIET THERAPY PATIENT INTAKE FORMS

Certified Raw Food Nutrition Specialist will prepare food


list, and detailed report, for hundreds of health concerns:
Please print both forms, and read information below:
DIET THERAPY PATIENT INTAKE FORMS

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DIET THERAPY PATIENT INTAKE FORMS

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DIET THERAPY PATIENT INTAKE FORMS

DIET THERAPY PATIENT INTAKE FORMS


Print both forms and Fill out information as best you can.
Please be sure to read all information below to see what health
concerns apply to you, and write them on back of either diet
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DIET THERAPY PATIENT INTAKE FORMS

therapy forms.
I will print you a food list, showing foods that are bad, and foods
that are good, in relation to your specfic health concern.
I will also print for you a detailed report on each specfic health
concern.
25 dollars includes food list and detailed report per health concern.
Please send a check for 25 dollars per health concern, and mail
with Diet Therapy Patient Intake Forms, to ........ Richard Adkins
10512 Snyder Avenue Las Vegas, NV 89134
Be sure to include your name and return address, So I can mail you all your documents.

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DIET THERAPY PATIENT INTAKE FORMS

Acne (vulgaris)
Possible predisposing factors: Diets high in refined carbohydrates, Hormonal
insufficiency or imbalance, Excess iron in diet, Insufficient vitamin A and E in diet,
Insufficient zinc or magnesium in diet
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Sulfur and zinc

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DIET THERAPY PATIENT INTAKE FORMS

Selection this option will decrease: High iodine foods, All other contraindicated food
items

Adrenals
Highlights food items demonstrated to support normal adrenal health and function.
Reduces consumption of items that compromise adrenal

Adrenal Dominant (Adrenal type


Distribution of patient's body fat is controlled primarily by adrenal hormones.

Adernal Hyper-function
Possible predisposing factors: Adrenal tumor, Anterior pituitary dysfunction, Increased
cortisol production
Selecting this option will increase: Potassium, Essential fatty acids, beneficial items
specific to condition
Selecting this option will decrease: All contraindicated food items

Adrenal Hypo-function
Possible predisposing factors: Chronic illness, Reactive hypoglycemia, Chronic stress,
Decreased cortisol production
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Sodium, Phytosterols, Essential fatty acids
Selecting this option will decrease: High gluten grains, Mercury contaminated seafood,
Casein, All other contraindicated food items

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DIET THERAPY PATIENT INTAKE FORMS

AIDS
Possible predisposing factors: HIV
Selecting this option will increase: Fiber, Cruciferous vegetables, Essential fatty acids,
Beneficial items specific to condition
Selecting this option will decrease: Mercury contaminated seafood, All other
contraindicated food items

Alcohol
Highlights in red print all food items and liquids containing alcohol

Alcoholism
Possible predisposing factors: Genetic predisposition, Learned coping behavior,
Mismanaged spiritual issues
Selecting this option will increase: Vitamin B-1, High protein foods, Food items that
support liver function, Essential fatty acids, Beneficial items specific to condition
Selecting this option will decrease: Alcohol, Common "trigger" food items, All other
contraindicated food items

All Toxic and Questionable Foods


Highlights all food items (including organic foods) that typically contain heavy metals,
nitrates, nitrites, harmful phenolics, aflatoxins, or toxic chemicals. Also highlights foods
that are known to be carcinogenic, or have been demonstrated to be harmful to human
health. This is a recommended selection for patients with extremely compromised health
or disease conditions of unknown etiology

Alzheimer's Disease
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DIET THERAPY PATIENT INTAKE FORMS

Possible predisposing factors: Heavy metal toxicity, Vitamin B-12 deficiency, Immune
Dysfunction, Zinc deficiency, Reduced blood supply to the brain, Exposure to chemicals,
pesticides, etc, Genetic predisposition
Selecting this option will increase: High sulfer food items, Food items that support blood
flow, Essential fatty acids, Beneficial items specific to condition
Selecting this option will decrease: Mercury contaminated seafood, Alcohol, Chemically
contaminated food items, All known contraindicated food items

Amenorrhea
Possible predisposing factors: Tumors, cysts, endometiosis, Hormonal imbalance, Diets
high in refined carbohydrates, Lack of essential fatty acids, Anemia, Low body fat
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Food items that support ovaries, Phytoestrogens, High protein foods
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Harmful fats and proteins

Anaerobic Imbalance (anabolic excess)


Anaerobic imbalance represents an insufficiency of oxidative metabolism.

Anemia macro and microcytic)


Possible predisposing factors: Poor digestive function, Internal bleeding, Vegetarian
diets, Excessive blood loss from menses
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Iron
Selecting this option will decrease: All known contraindicated food items, Phytates,
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DIET THERAPY PATIENT INTAKE FORMS

Black tea (blocks iron assimilation)

Angina Pectoris
Possible predisposing factors: Artherosclerosis, Cororary insufficiency, Oxygen
deficiency,
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Fiber
Selecting this option will decrease: All known contraindicated food items, Spicy foods,
Saturated fats, Other harmful fats and proteins, High gluten foods

Anxiety
Possible predisposing factors: Reactive hypoglycemia, Vitamin B complex deficiency,
Calcium or magnesium deficiency, Psychological stress, Food allergy or sensitvity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods,
Selecting this option will decrease: All known contraindicated food items, Refined
sugars, Caffeine, Harmful fats and proteins

Appetite (excess)
Possible predisposing factors: Intestinal parasites, Bowel flora imbalance, Hyper or
hypochlorhydria, Reactive hypoglycemia, Carbohydrate sensitivity (dysinsulinism)
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Fiber
Selecting this option will decrease: All known contraindicated food items

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DIET THERAPY PATIENT INTAKE FORMS

Appetite (reduced)
Possible predisposing factors: Intestinal parasites, Bowel flora imbalance, Hyper or
hypochlorhydria, Chronic conditions
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Fiber, Appetite stimulating spices
Selecting this option will decrease: All known contraindicated food items
Arrhythmia (Cardiac)
Possible predisposing factors: Vitamin B-1 deficiency, Copper deficiency, Cardiac
damage, Magnesium deficiency, Autonomic nervous system dysfunction, Food allergy or
sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Harmful fats and proteins, High glycemic index foods, Common
food allergens

Arrythmia (cardiac
Possible predisposing factors: Vitamin B-1 deficiency, Copper deficiency, Cardiac
damage, Magnesium deficiency, Autonomic nervous system dysfunction, Food allergy or
sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Harmful fats and proteins, High glycemic index foods, Common
food allergens

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DIET THERAPY PATIENT INTAKE FORMS

Arteriosclerosis
Possible predisposing factors: Genetic predisposition, Diets high in refined carbohydrates,
Alcohol consumption, Diets high in red meat or saturated fats, Diabetes, Carbohydrate
sensitivity, Homocystinuria
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, High gluten foods, Foods that support liver function

Arthritis (Osteo)
Possible predisposing factors: Genetic predisposition, Diets high in refined carbohydrates,
Excess consumption of alcohol, Excess consumption of caffeine, Thyroid and or
parathyroid dysfunction, Excess use of antacids
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support bone health
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Nightshade family foods

Arthritis (Rheumatoid)
Possible predisposing factors: Viral infection, Yeast infection, Parasites (especially
amoebic), Food or enviromental sensitivities, Poor protein digestion, Heavy metal
toxicity (Hg, Cu common), Genetic predisposition
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Gamma-linolenic acid
Selecting this option will decrease: All known contraindicated food items, High glycemic
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DIET THERAPY PATIENT INTAKE FORMS

index foods, Common food allergens

Asthma
Possible predisposing factors: Intestinal parasites, Hypochlorhydria, Heavy metal
toxicity, Food or environmental sensitivities, Adrenal cortical dysfunction
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High saturated fat foods, Common food allergens, Sulfites

Atherosclerosis
Possible predisposing factors: Genetic predisposition, Diets high in refined carbohydrates,
Alcohol consumption, Diets high in red meat or saturated fats, Diabetes, Carbohydrate
sensitivity, Homocystinuria
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, High gluten foods, Foods that support liver function

Attention Deficit Disorder (ADD)


Possible predisposing factors: Birth trauma, Heavy metal toxicity, Intestnal parasites,
Malnutrition, Iron B-6 or magnesium deficiency, Food or enviromental sensitivites,
Carbohydrate sensitivity, Brain virus, Endocrine dysfunction
Selecting this option will increase: High protein foods, Essential fatty acids, Beneficial
items specific to condition

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, Mercury contaminated seafood

Autism
Possible predisposing factors: Neurological dysfunction, Chemical toxicity, Viral
infection, Genetic predisposition, Fatty acid dysmetabolism
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Fiber
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods

Bacterial Infection
Possible predisposing factors: Contact with infecting organism, Immune deficiency,
Oxidative stress, Acid/alkaline imbalance
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Anti-bacterial foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Mucous producing foods

Bad Breath (halitosis


Possible predisposing factors: Sinus infection, Periodontal infection, Digestive
insufficiency, Intestinal flora imbalance
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Refined
sugars, Hard-to-digest proteins
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DIET THERAPY PATIENT INTAKE FORMS

Bed Wetting (enuresis


Possible predisposing factors: Physical or psychological trauma, Food sensitivity,
Bladder atonicity, Pituitary/hypothalamus dysfunction, Urinary tract infection, Pelvic
imbalance (chiropractic, Adrenal hypo function
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Vitamin B-2, Vitamin B-5, High protein foods
Selecting this option will decrease: All known contraindicated food items, Most common
food allergens

Bell's Palsy
Possible predisposing factors: Viral infection of facial nerves, Trauma, Nerve
inflammation
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Anti-viral food items, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated food items

Biliary Stasis/ Biliary Insufficiency


Possible predisposing factors: High refined carbohydrate diets, Female thyroid or ovarian
imbalance, Obesity, Lack of exercise, Chronic dehydration, Hypochlorhydria, Genetic
predisposition, Food sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids
Selecting this option will decrease: All known contraindicated food items, Common food
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DIET THERAPY PATIENT INTAKE FORMS

allergens, Cabbage family foods

Bipolar Depression
Possible predisposing factors: Food allergy or sensitivity, Psychological stress or trauma,
Vitamin B-1 deficiency, Endocrine hypo function, Carbohydrate sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Vanadium,
Cabbage family foods, Common food allergens

Bladder
Highlights food items demonstrated to support normal bladder health and function

Bleeding Gums
Possible predisposing factors: Genetic predisposition, Poor dental hygiene, High refined
carbohydrate diets, Infection, Chronic dehydration, Vitamin B-12 deficiency
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Dairy foods

Body Odor
Possible predisposing factors: Digestive dysfunction, Hormonal imbalance, Magnesium
deficiency

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support lymphatic system
Selecting this option will decrease: All known contraindicated food items, Harmful fats,
Common high hormone content foods

Bones
Highlights food items demonstrated to support normal bone health and function. Reduces
consumption of items that compromise bone integrity

Bone Spurs
Possible predisposing factors: Thyroid hypo function, Mineral insufficiency, Digestive
dysfunction
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Foods that support bone health
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High gluten foods

Bradycardia
Possible predisposing factors: Endocrine hypo function, Food allergy or sensitivity,
Vitamin B-1 deficiency, Genetic predisposition, Regular aerobic exercise
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support heart health, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
allergens

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DIET THERAPY PATIENT INTAKE FORMS

Brain/Nerves (CNS
Highlights food items demonstrated to support normal brain and nervous system health
and function. Reduces consumption of items that are harmful to either system

Bronchi
Highlights food items demonstrated to support normal bronchial health and function

Bronchitis
Possible predisposing factors: Iodine deficiency (in chronic cases, Environmental
sensitivity, Bacterial or viral infection, Adrenal insufficiency/fatigue, Diets high in
processed foods
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Citrus foods, Mucous producing foods

Bruxism
Possible predisposing factors: Calcium or magnesium deficiency, Misalignment of jaw
(chiropractic, TMJ dysfunction, Intestinal parasites, Psychological stress, Diets high in
processed foods, Food or environmental sensitivity, Excess caffeine intake
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
allergens

Bursitis
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DIET THERAPY PATIENT INTAKE FORMS

Possible predisposing factors: Injury, Bone spurs, Tissue alkalinity, Inflammation from
repeated motion
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Foods that support muscle function
Selecting this option will decrease: All known contraindicated food items, Foods that
promote inflammation

Burns (1st, 2nd and 3rd degree


Possible predisposing factors: Excess exposure to sun light, Exposure to high heat source
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High water content foods
Selecting this option will decrease: All known contraindicated food items, Alcohol

Burning Feet
Possible predisposing factors: Portal congestion, Liver/biliary dysfunction, Essential fatty
acid deficiency, Magnesium deficiency (with foot odor
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Foods that support liver/biliary function
Selecting this option will decrease: All known contraindicated food items

Caffeine
Highlights in red print all food items and liquids containing caffeine

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DIET THERAPY PATIENT INTAKE FORMS

Cancer (non-specific
Possible predisposing factors: Genetic predisposition, Consumption of carcinogens,
Environmental factors, Excess psychological stress, Excess physical stress, Immune
dysfunction
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Cruciferous foods, Fiber, Foods that support immune function
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Immune suppressing food items, Harmful fats and proteins

Canker Sores
Possible predisposing factors: Poor dental hygiene, Irritation from dental work, Food
allergies, Nutritional deficiencies, Hormonal imbalances, Viral infection, Immunological
disease, Stress, Fatigue
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Anti-bacterial food items, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Common food allergens, Common "trigger" foods

Carbohydrate Sensitivity
Possible predisposing factors: Excess carbohydrate consumption, Yeast or fungal
infection, Adrenal hypo function, Digestive dysfunction, Vitamin B-1 deficiency,
Magnesium or potassium deficiency, Reactive hypoglycemia, Genetic predisposition
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support pancreatic function, High protein foods
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, High gluten foods, Casein

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DIET THERAPY PATIENT INTAKE FORMS

Carcinogenic Foods
Highlights food items that research has shown to increase the risk of cancer in humans or
laboratory animals.

Cardiac Arrhythmia
Possible predisposing factors: Vitamin B-1 deficiency, Copper deficiency, Cardiac
damage, Magnesium deficiency, Autonomic nervous system dysfunction, Food allergy or
sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Harmful fats and proteins, High glycemic index foods, Common
food allergens

Cataracts
Possible predisposing factors: Free radical exposure
Selecting this option will increase: Beneficial items specific to condition, Foods that
support eye function
Selecting this option will decrease: All known contraindicated food items, "Congestive"
food items, High saturated fat foods, Common pesticide contaminated foods

Cavities (dental caries


Possible predisposing factors: Oral bacterial disease, Poor oral hygiene, Diets high in
refined carbohydrates, Chronic acidic saliva

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, Food items that support dental health
Selecting this option will decrease: All known contraindicated food items

Celiac Disease (sprue


Possible predisposing factors: Genetic predisposition, Psychological stress, Food allergy
or sensitivity, Parasites, Digestive dysfunction, Biliary/pancreatic insufficiency
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All gluten containing foods, Brassica family foods,
Dairy foods, Spicy trigger foods

Chemotherapy (support during


Possible predisposing factors: Chemotherapy treatment
Selecting this option will increase: Omega 3 fatty acids, Fiber, Vitamin C, Food items
that support liver function
Selecting this option will decrease: All known contraindicated food items

Chicken Pox
Possible predisposing factors: Viral infection
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Anti-viral food items
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Mucous producing food items

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DIET THERAPY PATIENT INTAKE FORMS

Cholesterol Decreased (HDL


Possible predisposing factors: Immune dysfunction, Vegetarian diets, Endocrine hyper
function, Liver/biliary dysfunction, Manganese deficiency
Selecting this option will increase: Beneficial items specific to condition, Saturated fats,
Spicy food items, Essential fatty acids, High cholesterol foods, Foods that support liver
function
Selecting this option will decrease: All known contraindicated food items

Cholesterol Elevated (LDL


Possible predisposing factors: Diets high in carbohydrates, Diets high in saturated fats,
Lack of exercise, Obesity, Endocrine dysfunction, Genetic predisposition, Prolonged
bowel transit time, Carbohydrate sensitivity
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Phytosterols, Fiber
&n
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Spicy food items, Highest carbohydrate food items

Chronic Fatigue Syndrome (CFS


Possible predisposing factors: Viral infection, Yeast or fungal infection, Parasites,
Carbohydrate sensitivity, Magnesium deficiency, Heavy metal toxicity, "Leaky Gut"
syndrome
Selecting this option will increase: Beneficial items specific to condition, Anti-viral foods
items, High protein foods, Fiber, Omega 3 fatty acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Mercury contaminated seafood
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DIET THERAPY PATIENT INTAKE FORMS

Circulation Reduced
Possible predisposing factors: Anemia, Atherosclerosis, Thyroid hypo function, Adrenal
hypo function, B vitamin deficiency
Selecting this option will increase: Beneficial items specific to condition, Stimulatory
food items, Foods that support thyroid function, Foods that support adrenal function,
Foods that support circulation, Foods that increase hydration
Selecting this option will decrease: All known contraindicated food items, Foods that
suppress thyroid function

Cirrhosis (hepatic
Possible predisposing factors: Alcoholism, Drug abuse, Diabetes, Viral infection
(hepatitis, Exposure to chemicals, Heavy metal toxicity, Malnutrition
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Fiber, High protein foods
Selecting this option will decrease: All known contraindicated food items, Foods that
congest the liver, High saturated fat foods

Cold Hands/Feet
Possible predisposing factors: Anemia, Atherosclerosis, Thyroid hypo function, Adrenal
hypo function, B vitamin deficiency
Selecting this option will increase: Beneficial items specific to condition, Pungent
(stimulatory) food items, Foods that support thyroid function, Foods that support adrenal
function, Foods that support circulation, Foods that increase hydration
Selecting this option will decrease: All known contraindicated food items, Foods that
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DIET THERAPY PATIENT INTAKE FORMS

suppress thyroid function

Cold Sores (HSV-1


Possible predisposing factors: Herpes Simplex virus, Food allergy or sensitivity,
Hypochlorhydria, Intestinal flora imbalance, Biliary stasis or insufficiency, Calcium or
magnesium deficiency, Adrenal cortical hyper function, High arginine diets
Selecting this option will increase: Beneficial items specific to condition, Lysine, Antiviral food items, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Most common
food allergens, High arginine food items

Colic (Mother's or child's diet)


Possible predisposing factors: Milk or formula sensitivity, Breast feeding mother has poor
diet, Thymus hypo function, Intestinal flora imbalance, Viral or bacterial infection,
Physiological problem in bowel
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Common food
triggers

Colitis (ulcerative
Possible predisposing factors: Psychological stress, Food allergy or sensitivity, Infection,
Genetic predisposition, Parasites, Hypochlorhydria, Bowel flora imbalance, Biliary or
pancreatic insufficiency
Selecting this option will increase: Beneficial items specific to condition, Fiber, Vitamin
K

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Common food
triggers, High fat food items

Common Cold,
Possible predisposing factors: Viral infection, Reduced immune function, Physical or
psychological stress, Malnutrition
Selecting this option will increase: Beneficial items specific to condition, Vitamin C
(from non-citrus sources, High protein foods, Carotenes, Anti-viral food items
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Citrus fruits (these are contraindicated

Congestive Heart Failure (CHF


Possible predisposing factors: Cardiac disease, Diets high in carbohydrates, Diets high in
saturated fats, Carbohydrate sensitivity, Infection, Arthero or arteriosclerosis
Selecting this option will increase: Beneficial items specific to condition, Potassium,
Fiber, Foods that increase hydration, Foods that support heart function, Foods that support
kidney function
Selecting this option will decrease: All known contraindicated food items, High sodium
food items, Brassica family foods, Saturated and other harmful fats

Constipation
Possible predisposing factors: Food allergy or sensitivity, Pyloric or ileocecal valve
dysfunction, Dehydration, Diets low in fiber, Diets high in refined carbohydrates, Lack of
exercise, Hypochlorhydria
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber, Bowel flora, Vitamin C, Foods that support biliary function

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Common food
triggers, Hard-to-digest food items

Copper toxicity
Possible predisposing factors: Genetic predisposition, Elevated urine kryptopyrole, Zinc
deficiency, Vegetarian diet, Copper water supply pipes, Chronic infection, Chronic
elevated estrogen, Adrenal insufficiency
Selecting this option will increase: Beneficial items specific to condition, Sulfur, Zinc,
Vitamin C, Hydration, Fiber, Essential fatty acids, Foods that support liver function, High
protein foods
Selecting this option will decrease: All known contraindicated food items, Copper intake

Coronary Artery Disease (CAD


Possible predisposing factors: High carbohydrate diets, High saturated fat diets, Genetic
predisposition, Excess alcohol consumption, Endocrine dysfunction, Homocystinuria
Selecting this option will increase: Beneficial items specific to condition, Fiber, Essential
fatty acids, Foods that support heart function
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, High gluten foods

Cramps (menstrual
Possible predisposing factors: Hormonal imbalance, Unstable blood sugar, Food allergy
or sensitivity, Diets high in refined carbohydrates, Calcium deficiency, Fatty acid
metabolism problems, Malabsorption
Selecting this option will increase: Beneficial items specific to condition, Fiber,
Phytoestrogens, Hydration, Bowel flora
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, High sodium
food items, High saturated fat foods

Crohn's Disease
Possible predisposing factors: Genetic predisposition, Viral or bacterial infection
(triggers, Immune hyper function,
Selecting this option will increase: Beneficial items specific to condition, Hydration
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods

Cystic Fibrosis
Possible predisposing factors: Genetic predisposition
Selecting this option will increase: Beneficial items specific to condition, Foods that
support lung function, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods

Cystitis (interstitial
Possible predisposing factors: Bladder inflammation, Very high or low urine pH, Immune
dysfunction, Food or environmental sensitivity, Dehydration, Bacterial, viral or yeast
infection

Cytomegalovirus (CMV
Possible predisposing factors: Contact with infected person, Oxidative stress,
Acid/alkaline imbalance
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Fiber, High protein foods, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat food items, Mercury contaminated seafood
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, Hydration, Foods that support bladder health
Selecting this option will decrease: All known contraindicated food items, Common food
triggers, Mercury contaminated seafood

Dairy (casein and lactose


Highlights all foods that contain casein or lactose in red print
Degenerative Joint Disease (DJD
Possible predisposing factors: Genetic predisposition, Diets high in refined carbohydrates,
Thyroid/parathyroid dysfunction
Selecting this option will increase: Beneficial items specific to condition, Foods that
support joint function, Food that support bone health
Selecting this option will decrease: All known contraindicated food items, Nightshade
family foods, High saturated fat foods

Dental Caries (cavities


Possible predisposing factors: Oral bacterial disease, Poor oral hygiene, Diets high in
refined carbohydrates, Chronic acidic saliva
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, Food items that support dental health

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Refined sugars

Depression
Possible predisposing factors: Food allergy or sensitivity, Psychological stress, Vitamin
B-1 deficiency, Endocrine hypo function, Carbohydrate sensitivity
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Foods that support nervous system
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Casein

Dermatitis
Possible predisposing factors: Gluten or dairy sensitivity, Hypochlorhydria, Digestive
dysfunction, Bowel flora imbalance, Diets high in hydrogenated fats and oils, Calcium or
magnesium deficiency
Selecting this option will increase: Beneficial items specific to condition, Foods that
support healthy skin
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Dairy foods, Harmful fats

Detoxification (general support


Possible predisposing factors: Detoxification therapy
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber, Foods that support liver/biliary function
Selecting this option will decrease: All known contraindicated food items, Foods that
congest digestive system, Mercury contaminated seafood
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DIET THERAPY PATIENT INTAKE FORMS

Diabetes (type I)
Possible predisposing factors: Mineral deficiency, Genetic predisposition, Obesity, Lack
of exercise, Endocrine dysfunction, Type IV Hyperlipoproteinemia, Carbohydrate
sensitivity (Syndrome X), Viral Infection
Selecting this option will increase: Beneficial items specific to condition, Sulfur, Vitamin
B-3, Fiber, Foods that support pancreatic function, Chromium
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, High gluten foods, Harmful fats

Diabetes (type II)


Possible predisposing factors: Excessive sugar intake, High carbohydrate diet, Mineral
deficiency, Genetic predisposition, Obesity, Lack of exercise, Endocrine dysfunction,
Type IV Hyperlipoproteinemia, Carbohydrate sensitivity (syndrome X
Selecting this option will increase: Beneficial items specific to condition, Sulfur, Vitamin
B-3, Fiber, Foods that support pancreatic function, Chromium
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, High gluten foods, Harmful fats

Diarrhea
Possible predisposing factors: Food allergy or sensitivity, Infection, Psychological stress,
Parasites, Bowel flora imbalance
Selecting this option will increase: Beneficial items specific to condition, Fiber,
Hydration, Foods that support digestive system, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Common food
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DIET THERAPY PATIENT INTAKE FORMS

triggers

Digestive Distress (indigestion


Possible predisposing factors: Food allergy or intolerance, Hypochlorhydria, Digestive
enzyme deficiency, Peptic ulcer, Eating too fast, Stomach or intestine disorders
Selecting this option will increase: Beneficial items specific to condition, Foods that
support digestion, Foods that support biliary function, Fiber
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods

Diverticulosis
Possible predisposing factors: Low fiber diets, Chronic dehydration, Chronic difficulty
voiding stools
Selecting this option will increase: Beneficial items specific to condition, Foods that
support intestinal health, Fiber, Hydration
Selecting this option will decrease: All known contraindicated food items, Foods that
exacerbate diverticulitis

Drug Addiction
Possible predisposing factors: Genetic predisposition, Learned coping behavior,
Mismanaged spiritual issues, Long term prescription pain control
Selecting this option will increase: Beneficial items specific to condition, Vitamin B-1,
High protein foods, Foods that support liver function, Foods that support nervous system,
Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Alcohol,
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DIET THERAPY PATIENT INTAKE FORMS

Refined sugars

Dry Skin
Possible predisposing factors: Dysfunctional fatty acid metabolism, Excess sunlight
exposure, Dehydration, Alcohol consumption
Selecting this option will increase: Beneficial items specific to condition, Sulfur, Foods
that support healthy skin, Essential fatty acids, Hydration
Selecting this option will decrease: All known contraindicated food items, Alcohol,
Harmful fats and oils

Duodenal Ulcer
Possible predisposing factors: Excess or insufficient HCL production, Biliary or
pancreatic dysfunction, Bacterial infection, Pyloric or ileocecal valve dysfunction,
Chronic stress, Food allergy or sensitivity, Aspirin overuse, Overuse of some medications
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High fat content foods, Spicy foods

Dysmenorrhea
Possible predisposing factors: Tumors or cysts, Endometriosis, Hormonal imbalance,
Diets high in refined carbohydrates, Lack of essential fatty acids, Anemia
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Hydration, Foods that support ovarian function, Phytoestrogens, Essential fatty
acids
Selecting this option will decrease: All known contraindicated food items, Dairy
products, High gluten foods
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DIET THERAPY PATIENT INTAKE FORMS

Dysaerobic Imbalance (catabolic excess)


Dysaerobic imbalance represents uncontrolled oxidative free radical reactions with
peroxide formation.

Dyspepsia (indigestion
Possible predisposing factors: Food allergy or intolerance, Hypochlorhydria, Digestive
enzyme deficiency, Peptic ulcer, Eating too fast, Stomach or intestine disorders
Selecting this option will increase: Beneficial items specific to condition, Foods that
support digestion, Foods that support biliary function, Fiber
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods

Ears (hearing
Highlights food items demonstrated to support normal hearing health and function

Ear Infections
Possible predisposing factors: Bacterial or viral infection, Food allergy or sensitivity,
Adrenal hypo function, Diets high in refined carbohydrates
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, High protein foods, Foods that support ear health
Selecting this option will decrease: All known contraindicated food items, Dairy
products, High gluten foods

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DIET THERAPY PATIENT INTAKE FORMS

Eczema
Possible predisposing factors: Gluten or dairy sensitivity, Hypochlorhydria, Digestive
dysfunction, Bowel flora imbalance, Diets high in hydrogenated fats and oils, Calcium or
magnesium deficiency
Selecting this option will increase: Beneficial items specific to condition, Foods that
support healthy skin, Sulfur, Hydration
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Dairy foods, High saturated fat foods

Edema
Possible predisposing factors: Cardiac/renal dysfunction, Food allergy or sensitivity,
Adrenal hypo function, Tissue inflammation, B vitamin deficiency, Ascites
Selecting this option will increase: Beneficial items specific to condition, Foods that
support kidney function, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Sodium,
Common food allergens, Red meat

Emphysema
Possible predisposing factors: Environmental sensitivity, Smoking, Adrenal hypo
function, Increased RBC count
Selecting this option will increase: Beneficial items specific to condition, High protein
foods
Selecting this option will decrease: All known contraindicated food items, Most common
food triggers

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DIET THERAPY PATIENT INTAKE FORMS

Endometriosis
Possible predisposing factors: Chemical exposure, Chronic stress, Hormonal imbalances,
Obesity, Lack of exercise, Infertility
Selecting this option will increase: Beneficial items specific to condition, Foods that
support female organs, Fiber
Selecting this option will decrease: All known contraindicated food items, Red meat,
Shellfish, Dairy products

Enuresis (bed wetting


Possible predisposing factors: Physical or psychological trauma, Food sensitivity,
Bladder atonicity, Pituitary/hypothalamus dysfunction, Urinary tract infection, Pelvic
imbalance (chiropractic, Adrenal hypo function
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Vitamin B-2, Vitamin B-5, High protein foods
Selecting this option will decrease: All known contraindicated food items, Most common
food allergens

Epilepsy (seizure disorders


Possible predisposing factors: Heavy metal toxicity, Intestinal parasites, Food allergy or
sensitivity, Reactive hypoglycemia, Manganese or magnesium deficiency, Vitamin B-6
deficiency, Head injury, Brain infection
Selecting this option will increase: Beneficial items specific to condition, Manganese,
Magnesium, Vitamin B-6, Foods that support nervous system
Selecting this option will decrease: All known contraindicated food items, All common
food triggers, Mercury contaminated seafood

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DIET THERAPY PATIENT INTAKE FORMS

Epstein Barr Virus (EBV


Possible predisposing factors: Contact with infected person
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Fiber, High protein foods, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat food items, Mercury contaminated seafood

Excessive Appetite
Possible predisposing factors: Intestinal parasites, Bowel flora imbalance, Hyper or
hypochlorhydria, Reactive hypoglycemia, Carbohydrate sensitivity (dysinsulinism
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Fiber
Selecting this option will decrease: All known contraindicated food items

Eyes (vision
Highlights food items demonstrated to support normal eye health and function

Fast Oxidation Dominant


Patient's metabolism is primarily being controlled by fast cellular oxidation

Fatigue (prolonged or CFS


Possible predisposing factors: Viral infection, Yeast or fungal infection, Parasites,
Carbohydrate sensitivity, Magnesium deficiency, Heavy metal toxicity, "Leaky Gut"
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DIET THERAPY PATIENT INTAKE FORMS

syndrome
Selecting this option will increase: Beneficial items specific to condition, Anti-viral foods
items, High protein foods, Fiber, Omega 3 fatty acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Mercury contaminated seafood

Feet Burning
Possible predisposing factors: Portal congestion, Liver/biliary dysfunction, Essential fatty
acid deficiency, Magnesium deficiency (with foot odor
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Foods that support liver/biliary function
Selecting this option will decrease: All known contraindicated food items

Female Frigidity
Possible predisposing factors: Psychological stress or trauma, Hormonal imbalance,
Thyroid hypo function, Reactive hypoglycemia, Diets high in refined carbohydrates
Selecting this option will increase: Beneficial items specific to condition, Foods that
support female sex organs, Phytoestrogens, Hydration, High protein foods
Selecting this option will decrease: All known contraindicated food items

Female Infertility
Possible predisposing factors: Endometriosis, Blocked fallopian tubes, Irregular
ovulation, Low progesterone production, Over 34 years of age, Previous infection
Selecting this option will increase: Beneficial items specific to condition, Phytoestrogens,
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DIET THERAPY PATIENT INTAKE FORMS

Hydration, High protein foods, Foods that support ovaries, Arginine


Selecting this option will decrease: All known contraindicated food items

Female Reproductive Organs


Highlights food items demonstrated to support normal ovarian health and function.
Reduces consumption of cottonseed oil which is harmful to ovaries.

Fever
Possible predisposing factors: Infection, Lowered immune function, Physical or
psychological stress,
Selecting this option will increase: Beneficial items specific to condition, Hydration
Selecting this option will decrease: All known contraindicated food items, Iron, Zinc

Fibrocystic Breast Disease


Possible predisposing factors: Normal female hormone cycles, Lymphatic congestion
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Iodine, Foods that support mammary glands, Foods that support lymphatic system
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods

Fibroids (uterine
Possible predisposing factors: Genetic predisposition, Ethnic background, Estrogen
intolerance
Selecting this option will increase: Beneficial items specific to condition, Foods that
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DIET THERAPY PATIENT INTAKE FORMS

support liver function, High protein foods, Hydration, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Sodium, High
saturated fat

Fibromyalgia
Possible predisposing factors: Food allergy or sensitivity, Heavy metal toxicity, Immune
system dysfunction, Magnesium or potassium deficiencies, Vitamin B-1 deficiency, Viral
infection, Candida infection, Suppressed psychological issues
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Hydration
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Nightshade family foods, High gluten foods, Dairy products, High
saturated fat foods, Common food allergens</item

Flatulence
Possible predisposing factors: Food sensitivity, Hypochlorhydria, Pancreatic
insufficiency, Bowel flora imbalance, Biliary stasis
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Most common
food triggers

Flu (influenza
Possible predisposing factors: Viral infection
Selecting this option will increase: Beneficial items specific to condition, Vitamin C,
Carotenes, Bowel flora, High protein foods, Anti-viral food items
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Citrus fruits
(these are contraindicated, Mercury contaminated seafood, Mucous producing foods

Fluoride/Chlorine
Highlights in red print liquids that commonly contain chlorine and fluoride

Food Items Children Should Avoid


Highlights in red print food items that are generally considered unhealthy for children to
consume.

Fractures
Possible predisposing factors: Trauma, Osteoporosis
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Omega 3 essential fatty acids, Foods that support bone growth, Hydration
Selecting this option will decrease: All known contraindicated food items

Fungal Infections
Possible predisposing factors: Prolonged antibiotic use, Hormone replacement therapy,
Adrenal dysfunction, High carbohydrate diets, Digestive dysfunction, Bowel flora
imbalance
Selecting this option will increase: Beneficial items specific to condition, Anti-fungal
foods
Selecting this option will decrease: All known contraindicated food items, High
carbohydrate foods, High sugar foods
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DIET THERAPY PATIENT INTAKE FORMS

Gall Bladder
Highlights food items demonstrated to support normal gall bladder health and function.
Reduces consumption of margarine and cottonseed oil which compromise gall bladder
function

Gall Bladder Dysfunction


Possible predisposing factors: High refined carbohydrate diets, Excess intake of
hydrogenated fats, Excess dairy food intake, Female hormone imbalances, Obesity, Lack
of exercise, Hypochlorhydria, Genetic predisposition, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Foods that
support gall bladder, Foods that support liver function
Selecting this option will decrease: All known contraindicated food items

Gallstones
Possible predisposing factors: High refined carbohydrate diets, Excess intake of
hydrogenated fats, Excess dairy food intake, >Female hormone imbalances, Obesity,
Lack of exercise, Hypochlorhydria, Genetic predisposition, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Foods that
support gall bladder, Foods that support liver function, Fiber
Selecting this option will decrease: All known contraindicated food items

Gastric Ulcer
Possible predisposing factors: Excess or insufficient HCL production, Biliary or
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DIET THERAPY PATIENT INTAKE FORMS

pancreatic dysfunction, Bacterial infection, Pyloric or ileocecal valve dysfunction,


Chronic stress, Food allergy or sensitivity, Aspirin or Advil overuse
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High fat content foods, Spicy foods

Genital-Urinary Infection (UTI


Possible predisposing factors: Poor personal hygiene, Nylon underwear, Sexually
transmitted infection, Sensitivity to toilet paper, tampons, etc.
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
foods, Hydration, Foods that support bladder function, Foods that support kidney function
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods, Mercury contaminated seafood

Glaucoma
Possible predisposing factors: Chronic stress, Antioxidant deficient diets, Diabetes, High
blood pressure, Collagen dysmetabolism, Excess dietary glutamate, Nitric oxide
deficiency, Atherosclerosis, Food allergy or sensitivity, Vitamin or mineral deficiencies
Selecting this option will increase: Beneficial items specific to condition, Foods that
support eye health, High protein foods
Selecting this option will decrease: All known contraindicated food items

Gluten Containing Foods (highest only


Highlights wheat, oats, rye and barley in red print. Though oats do not contain gluten,
they are nearly always contaminated with gluten from being ground in multi-grain
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DIET THERAPY PATIENT INTAKE FORMS

processing mills.

Gluten Containing Foods (all)


Highlights in red print all foods known to contain gluten, or those that are commonly
contaminated with gluten from being ground in multi-grain processing mills, or those that
have been proven to cause similar immune reactions as gluten

Goiter
Possible predisposing factors: Tumor, Manganese deficiency, Vitamin B-2 deficiency,
Excess brassica consumption, Iodine deficiency or excess
Selecting this option will increase: Beneficial items specific to condition, Hydrating,
High protein foods
Selecting this option will decrease: All known contraindicated food items

Gout
Possible predisposing factors: Stress, Diets high in purines, Hypochlorhydria, Renal
dysfunction, Liver/biliary dysfunction
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, High and
medium purine proteins, Nightshade family foods

Grinding of Teeth (bruxism


Possible predisposing factors: Calcium or magnesium deficiency, Misalignment of jaw
(chiropractic, TMJ dysfunction, Intestinal parasites, Psychological stress, Diets high in
processed foods, Food or environmental sensitivity, Excess caffeine intake
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
allergens

Gums/Teeth
Highlights food items demonstrated to support normal oral and dental health. Reduces
consumption of items which compromise dental health

Gums (bleeding or receding


Possible predisposing factors: Genetic predisposition, Poor dental hygiene, High refined
carbohydrate diets, Infection, Chronic dehydration, Vitamin B-12 deficiency
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Dairy foods

Hair/Scalp
Highlights food items demonstrated to support healthy hair and scalp.
Reduces consumption of soft drinks which compromise hair health

Halitosis
Possible predisposing factors: Sinus infection, Periodontal infection, Digestive
insufficiency, Intestinal flora imbalance
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition


Selecting this option will decrease: All known contraindicated food items, Refined
sugars, Hard-to-digest proteins

HDL Cholesterol Reduced


Possible predisposing factors: Immune dysfunction, Vegetarian diets, Endocrine hyper
function, Liver/biliary dysfunction, Manganese deficiency
Selecting this option will increase: Beneficial items specific to condition, Saturated fats,
Spicy food items, Essential fatty acids, High cholesterol foods, Foods that support liver
function</item>
Selecting this option will decrease: All known contraindicated food items

Headaches (non-migraine
Possible predisposing factors: Liver/biliary dysfunction, Food allergy or sensitivity,
Anemia, Bowel problems, Bruxism, Hypertension, Hypoglycemia, Spinal misalignment,
Sinusitis, Dehydration
Selecting this option will increase: Beneficial items specific to condition, Hydration,
High protein foods, Fiber
Selecting this option will decrease: All known contraindicated food items, Most common
food triggers

Heart
Highlights food items demonstrated to support cardiac health and function.
Reduces consumption of items which are harmful to heart health
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DIET THERAPY PATIENT INTAKE FORMS

Heavy Metal Toxicity


Possible predisposing factors: Dental fillings, Diets high in fish/seafood, Use of
aluminum cookware, Well water, Use of deodorants, Use of canned foods,
Environmental exposure, Vegetables grown at perimeter of home
Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Hydration, Foods that support liver function, Foods that support biliary function, Fiber
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood

Heel Spurs
Possible predisposing factors: Thyroid hypo function, Mineral insufficiency, Digestive
dysfunction
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Foods that support bone health
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High gluten foods

Hemochromatosis
Possible predisposing factors: Genetic predisposition, Multiple blood transfusions, Excess
ingestion of iron supplements, Use of iron cookware, Well water, Environmental
exposure, "Leaky Gut" syndrome, Liver, biliary or spleen dysfunction
Selecting this option will increase: Beneficial items specific to condition, Calcium, Fiber,
Phytates, Foods that support liver function
Selecting this option will decrease: All known contraindicated food items, Iron, Vitamin
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DIET THERAPY PATIENT INTAKE FORMS

C, Foods that impede liver function

Hemophilia
Possible predisposing factors: Genetic predisposition, Clotting factor VIII deficiency,
Clotting factor IX dysfunction
Selecting this option will increase: Beneficial items specific to condition, Vitamin K
Selecting this option will decrease: All known contraindicated food items

Hemorrhoids
Possible predisposing factors: Prolonged sitting or standing, Violent coughing, Lifting
heavy objects, Straining at bowel movements, Chronic dehydration, Lack of exercise,
Liver damage, Food allergy or sensitivity, Fiber deficient diets, Pregnancy
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber, Foods that support liver function, Foods that support biliary function, Essential
fatty acids
Selecting this option will decrease: All known contraindicated food items

Hepatic Cirrhosis
Possible predisposing factors: Alcoholism, Drug abuse, Diabetes, Hepatitis, Chemical
exposure, Heavy metal toxicity, Malnutrition
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Fiber, High protein foods
Selecting this option will decrease: All known contraindicated food items, Foods that
congest the liver, High saturated fat foods

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DIET THERAPY PATIENT INTAKE FORMS

Hepatic Disease (general support


Possible predisposing factors: Alcoholism, Drug abuse, Diabetes, Viral hepatitis,
Chemical exposure, Heavy metal toxicity, Malnutrition
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Fiber, High protein foods, Foods that support biliary function
Selecting this option will decrease: All known contraindicated food items, Foods that
congest the liver, High saturated fat foods

Hepatitis
Possible predisposing factors: Contact with infected person, Fecal food contamination,
Blood transfusions, Shared needles, Raw shellfish, Contracted through childbirth,
Chemical exposure, Alcohol or drug abuse
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Foods that support liver function, High protein foods, Hydration
Selecting this option will decrease: All known contraindicated food items, Shellfish, High
glycemic index foods, Mercury contaminated seafood, Red meat

Herpes Simplex (HSV-1


Possible predisposing factors: Contact with infected person, Contracted through
childbirth
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Lysine
Selecting this option will decrease: All known contraindicated food items, Arginine,
Trigger foods, Mercury contaminated seafood

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DIET THERAPY PATIENT INTAKE FORMS

Herpes Zoster (HSV-2


Possible predisposing factors: Varicella-zoster infection (Chicken pox, Stress, Cancer,
Chemotherapy, Spinal cord injury, Immunodeficiency
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, High protein foods, Essential fatty acids, Vitamin B-6
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood

Hiatal Hernia
Possible predisposing factors: Esophageal sphincter dysfunction, Food sensitivities,
Ulcers, Biliary dysfunction, Hypochlorhydria, Spinal misalignment, Stress
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, All common
trigger foods

High Blood Pressure (hypertension


Possible predisposing factors: Stress, Smoking, Endocrine hyper function, Obesity, Lack
of exercise, Renal dysfunction, Liver/portal congestion, Diabetes (type II),
Arthero/arteriosclerosis, Caffeine or sodium intake excess
Selecting this option will increase: Beneficial items specific to condition, Fiber, Essential
fatty acids
Selecting this option will decrease: All known contraindicated food items

High Blood Sugar (hyperglycemia


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DIET THERAPY PATIENT INTAKE FORMS

Possible predisposing factors: Mineral deficiency, Genetic predisposition, Obesity, Lack


of exercise, Endocrine dysfunction, Type IV Hyperlipoproteinemia, Carbohydrate
sensitivity (Syndrome X
Selecting this option will increase: Beneficial items specific to condition, Sulfur, Vitamin
B-3, Fiber, Foods that support pancreatic function, Chromium
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, High gluten foods, Harmful fats

High Cholesterol (LDL


Possible predisposing factors: Diets high in carbohydrates, Diets high in saturated fats,
Lack of exercise, Obesity, Endocrine dysfunction, Genetic predisposition, Prolonged
bowel transit time, Carbohydrate sensitivity
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Phytosterols
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Spicy food items, Highest carbohydrate food items

High Triglycerides
Possible predisposing factors: Alcohol consumption, Diets high in sugars, Diets high in
saturated fats, Carbohydrate sensitivity (Syndrome X
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Fiber
Selecting this option will decrease: All known contraindicated food items, High sugar
food items, High saturated fat foods

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DIET THERAPY PATIENT INTAKE FORMS

Hives (urticaria)
Possible predisposing factors: Food allergy or sensitivity, Contact with triggering
chemicals, Viral infection, Yeast infection, Antibiotic use, Drug use or abuse
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, All known
common food triggers

Homocystinuria
Possible predisposing factors: Artherosclerosis, Vitamin B-6 or B-12 deficiency, Folic
acid deficiency, Hypothyroidism, Genetic predisposition, Sulfur dysmetabolism
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids
Selecting this option will decrease: All known contraindicated food items, Sulfur

Hot Flashes (menopausal)


Possible predisposing factors: Hormonal imbalance, Iodine deficiency, Diets high in
refined carbohydrates, Alcohol or caffeine consumption, Excess hydrogenated fats and
oils, Obesity, Lack of exercise, Food allergy or sensitivity</item>
Selecting this option will increase: Beneficial items specific to condition, Phytoestrogens,
Phytosterols, Fiber, Hydration
Selecting this option will decrease: All known contraindicated food items, Sodium

Hyperglycemia (high blood sugar)


Possible predisposing factors: Mineral deficiency, Genetic predisposition, Obesity, Lack
of exercise, Endocrine dysfunction, Type IV Hyperlipoproteinemia, Carbohydrate
sensitivity (Syndrome X)</item>
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Sulfur, Vitamin
B-3, Fiber, Foods that support pancreatic function, Chromium
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, gluten foods, Harmful fats

Hyperkinesis (hyperactivity
Possible predisposing factors: Birth trauma, Heavy metal toxicity, Intestinal parasites,
Malnutrition, Iron, B-6 or magnesium deficiency, Carbohydrate sensitivity (Syndrome
X), Brain virus, Endocrine dysfunction
Selecting this option will increase: Beneficial items specific to condition, High protein
foods</item>
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, Stimulants

Hypertension (high blood pressure)


Possible predisposing factors: Stress, Smoking, Endocrine hyper function, Obesity, Lack
of exercise, dysfunction, Liver/portal congestion, Diabetes (type II),
Arthero/arteriosclerosis, Caffeine or sodium intake excess
Selecting this option will increase: Beneficial items specific to condition, Fiber, Essential
fatty acids
Selecting this option will decrease: All known contraindicated food items

Hyperthyroidism
Possible predisposing factors: Auto-immune disorder, Infection, Thyroid inflammation,
Space occupying thyroid lesion, Food allergy or sensitivity, Hormonal imbalance
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Brassica family
foods,
Selecting this option will decrease: All known contraindicated food items, Iodine,
Thyroid stimulating foods, Common food triggers

Hypochlorhydria (low stomach acid


Possible predisposing factors: Chronic illness, asthma, Endocrine dysfunction, Cancer,
Arthritis, Infections
Selecting this option will increase: Sodium, Zinc
Selecting this option will decrease: Food items that dilute acid

Hypoglycemia (low blood sugar


Possible predisposing factors: Diets high in carbohydrates, Endocrine hypo function,
Liver/biliary dysfunction, Hypochlorhydria, Genetic predisposition, Pancreatitis, Immune
deficiency, Candidiasis, Excess caffeine intake, Hyperinsulinemia
Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Chromium, Foods that support pancreatic function
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods

Hypotension (low blood pressure)


Possible predisposing factors: Endocrine hypo function, Vitamin B-1 deficiency, Food
allergy or sensitivity, Genetic predisposition, Iron anemia

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Sodium, Foods that support adrenal function
Selecting this option will decrease: All known contraindicated food items

Hypothyroidism
Possible predisposing factors: Iodine insufficiency, Fatty acid deficiency, Protein
deficiency, Hormonal imbalance, Drinking chlorinated water, High carbohydrate diets
Selecting this option will increase: Beneficial items specific to condition, Iodine, Foods
that support thyroid function
Selecting this option will decrease: All known contraindicated food items, Foods that
suppress thyroid function

Ileitis
Possible predisposing factors: Psychological stress, Food allergy or sensitivity, Infection,
Genetic predisposition, Parasites, Bowel flora imbalance, Hypochlorhydria
Selecting this option will increase: Beneficial items specific to condition, Vitamin K,
Fiber
Selecting this option will decrease: All known contraindicated food items, Common
trigger food items

Ileocecal Valve (ICV) Dysfunction


Possible predisposing factors: Food allergy or sensitivity, Parasites, Bowel flora
imbalance, Psychological stress, Post surgery traumatic stress
Selecting this option will increase: Beneficial items specific to condition

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Common food
triggers

Immune Depression (general


Possible predisposing factors: Heavy metal toxicity, Allergies, Diets high in
refined/processed foods, Diets high in hydrogenates, Use of alcohol, drugs, tobacco, Viral
or bacterial infection, Parasites, Free radical pathology, Physical stress, Psychological
stress
Selecting this option will increase: Beneficial items specific to condition, Hydration,
High protein foods, Foods that support liver function, Essential fatty acids
Selecting this option will decrease: Refined sugars, Mercury contaminated seafood, High
gluten foods, Unhealthy fats and oils, Generally unhealthy food items

Impotency (male
Possible predisposing factors: Hormonal imbalance, Adrenal stress, Zinc or other mineral
deficiency, Prostate hypertrophy
Selecting this option will increase: Beneficial items specific to condition, Arginine,
Vitamin B-6, Zinc, Foods that support male organs, High protein foods, Hydration
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Common mucous producing foods

Incontinence
Possible predisposing factors: Exertion, Weakened pelvic muscles, Obesity, aging or
pregnancy, Prostate inflammation, Pelvic inflammatory disease, Stimulants (caffeine,
alcohol, etc, Bladder infection, Abdominal surgery, Spinal cord injury, Neurological
impairment

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Foods that
support bladder health
Selecting this option will decrease: All known contraindicated food items

Indigestion (dyspepsia
Possible predisposing factors: Food allergy or intolerance, Hypochlorhydria, Digestive
enzyme deficiency, Peptic ulcer, Eating too fast, Stomach or intestine disorders
Selecting this option will increase: Beneficial items specific to condition, Foods that
support digestion, Foods that support biliary function, Fiber
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods

Infection (bacterial
Possible predisposing factors: Contact with infecting organism, Immune deficiency,
Oxidative stress, Acid/alkaline imbalance
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Anti-bacterial foods
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Mucous producing foods

Infection (ear
Possible predisposing factors: Food allergy or sensitivity, Adrenal hypo function,
Bacterial or viral infection, Diets high in refined carbohydrates
Selecting this option will increase: Beneficial items specific to condition, Anti-microbial
food items, Foods that support ears/ear canal

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Common
allergens/food triggers, Mercury contaminated seafood, Mucous producing food items

Infection (parasitic
Possible predisposing factors: Improperly washed food items, Improperly cooked food
items, Contact with household pets, Contact with infected person, Improperly purified
water, Hypochlorhydria
Selecting this option will increase: Beneficial items specific to condition, Anti-parasitic
food items, Sulfur
Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Foods that parasites thrive on, Mercury contaminated seafood

Infection (prostate
Possible predisposing factors: Infectious bacteria, Kidney or bladder infection, Hormonal
changes (age related, Sexual contact with infected person
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, High protein foods, Essential fatty acids, Foods that support prostate health
Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Mercury contaminated seafood

Infection (respiratory
Possible predisposing factors: Acute: bacterial or viral infection, Chronic: iodine
deficiency, Diets high in refined carbohydrates, Adrenal insufficiency
Selecting this option will increase: Beneficial items specific to condition, Foods that
support lungs and bronchi, High protein foods

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Mercury contaminated seafood

Infection (sinus
Possible predisposing factors: Bacterial or viral infection, Food or environmental
sensitivity, Sinus blockage, Constipation, Liver/biliary dysfunction
Selecting this option will increase: Beneficial items specific to condition, High protein
foods
Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Mercury contaminated seafood

Infection (urinary
Possible predisposing factors: Poor personal hygiene, Nylon underwear, Sexually
transmitted infection, Sensitivity to toilet paper, tampons, etc
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
foods, Hydration, Foods that support bladder function, Foods that support kidney function
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods, Mercury contaminated seafood

Infection (viral
Possible predisposing factors: Contact with infected person, Oxidative stress,
Acid/alkaline imbalance
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Fiber, High protein foods, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat food items, Mercury contaminated seafood
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DIET THERAPY PATIENT INTAKE FORMS

Infection (yeast/fungal
Possible predisposing factors: Prolonged antibiotic use, Hormone replacement therapy,
Adrenal dysfunction, High carbohydrate diets, Digestive dysfunction, Bowel flora
imbalance
Selecting this option will increase: Beneficial items specific to condition, Anti-yeast food
items
Selecting this option will decrease: All known contraindicated food items, High
carbohydrate foods, High sugar foods

Infertility (female
Possible predisposing factors: Endometriosis, Blocked fallopian tubes, Irregular
ovulation, Low progesterone production, Over 34 years of age, Previous infection
Selecting this option will increase: Beneficial items specific to condition, Phytoestrogens,
Hydration, High protein foods, Foods that support female sex organs, Arginine, Vitamin
B-6
Selecting this option will decrease: All known contraindicated food items, Gluten,
Mercury contaminated seafood

Infertility (male
Possible predisposing factors: Recent illness, Endocrine disorders, Varicoceles, Ulcer
medications, Genetic defects, Marijuana or cocaine use, History of venereal disease,
Urinary tract infections, Prostate hypertrophy, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Hydration, Arginine, Vitamin B-6, Zinc, Foods that support male sex organs

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will decrease: All known contraindicated food items, Gluten,
Mercury contaminated seafood

Inflammation (general
Possible predisposing factors: Infection, Trauma, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Isoflavones, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common
allergens, High saturated fat foods

Inflammation (vascular
Possible predisposing factors: Exogenous estrogen, Injury, Blood dyscrasias, Foods
allergy or sensitivity, Dehydration
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Foods that support vascular system
Selecting this option will decrease: All known contraindicated food items, Red meat
(exogenous estrogen, Common food triggers

Influenza (flu
Possible predisposing factors: Viral infection
Selecting this option will increase: Beneficial items specific to condition, Vitamin C,
Carotenes, Bowel flora, High protein foods, Anti-viral food items
Selecting this option will decrease: All known contraindicated food items, Citrus fruits
(these are contraindicated!), Mercury contaminated seafood, Mucous producing foods

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DIET THERAPY PATIENT INTAKE FORMS

Insomnia
Possible predisposing factors: Psychological disorders, Caffeine consumption, Hormonal
imbalances, Calcium or magnesium deficiency, Chronic illness/disease, Medications
Selecting this option will increase: Beneficial items specific to condition, Tryptophan
Selecting this option will decrease: All known contraindicated food items, Stimulant food
items

Interstitial Cystitis
Possible predisposing factors: Bladder inflammation, Very high or low urine pH, Immune
dysfunction, Food or environmental sensitivity, Dehydration, Bacterial, viral or yeast
infection
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, Hydration, Foods that support bladder health
Selecting this option will decrease: All known contraindicated food items, Common food
triggers, Mercury contaminated seafood

Intestinal Parasites
Possible predisposing factors: Improperly washed food items, Improperly cooked food
items, Contact with household pets, Contact with infected person, Improperly purified
water, Hypochlorhydria
Selecting this option will increase: Beneficial items specific to condition, Anti-parasitic
food items, Sulfur
Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Foods that parasites thrive on, Mercury contaminated seafood

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DIET THERAPY PATIENT INTAKE FORMS

Intestines (GI tract


Highlights food items demonstrated to support intestinal health and function. Reduces
consumption of cottonseed oil and margarine which are congestive to the intestines.

Irritable Bowel Syndrome (IBS


Possible predisposing factors: Intestinal hormone imbalances or bacterial infection,
Stress, Food allergy or sensitivity, Bowel flora imbalance
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Foods that support digestive tract, Fiber
Selecting this option will decrease: All known contraindicated food items, Most common
irritating/trigger foods

Joints
Highlights food items demonstrated to support joint health and function.
Reduces consumption of items which compromise joint health

Joint Pain
Possible predisposing factors: Arthritis, Excessive stress to joint, Repeated motion injury
Selecting this option will increase: Beneficial items specific to condition, Foods that
support joint health, Foods that support bone health
Selecting this option will decrease: All known contraindicated food items

Kidneys
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DIET THERAPY PATIENT INTAKE FORMS

Highlights food items demonstrated to support kidney health and function. Reduces
sodium which can adversely affect the kidneys.

Kidney Stones
Possible predisposing factors: Low urine pH, Parathyroid dysfunction, Vitamin D
intoxication, Multiple myeloma, Diets high in refined carbohydrates, Genetic
predisposition, Infection, Chronic dehydration, Cystinuria, Diets high in oxalic acid
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber
Selecting this option will decrease: All known contraindicated food items, Oxalates,
Potassium, Phosphorus

Lack of Sex Drive (female


Possible predisposing factors: Psychological stress or trauma, Hormonal imbalance,
Thyroid hypo function, Reactive hypoglycemia, Diets high in refined carbohydrates
Selecting this option will increase: Beneficial items specific to condition, Foods that
support female sex organs, Phytoestrogens, Hydration, High protein foods
Selecting this option will decrease: All known contraindicated food items

Lack of Sex Drive (male


Possible predisposing factors: Psychological disturbances, Hormonal imbalance, Mineral
deficiency, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Zinc, Hydration, Foods that support male sex organs
Selecting this option will decrease: All known contraindicated food items
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DIET THERAPY PATIENT INTAKE FORMS

Lactose Intolerance Casein intolerance

Lacto-ovo Vegetarian
Choosing this selection will eliminate all animal source food items except dairy products
and eggs

Lacto Vegetarian
Choosing this selection will eliminate all animal source food items except dairy products.

LDL Cholesterol Elevated


Possible predisposing factors: Diets high in carbohydrates, Diets high in saturated fats,
Lack of exercise, Obesity, Endocrine dysfunction, Genetic predisposition, Prolonged
bowel transit time, Carbohydrate sensitivity
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Phytosterols, Fiber
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Spicy food items, Highest carbohydrate food items

Liver
Highlights food items demonstrated to support liver health and function. Reduces
consumption of items that compromise liver health.

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DIET THERAPY PATIENT INTAKE FORMS

Liver-Colon Detoxification (support) Detoxification therapy


Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber, Foods that support liver function, Foods that support biliary function, Foods that
support intestinal function
Selecting this option will decrease: All known contraindicated food items, Constipating
food items, Foods that congest the liver, Mercury contaminated seafood

Liver Disease (general support


Possible predisposing factors: Alcoholism, Drug abuse, Diabetes, Viral hepatitis,
Chemical exposure, Heavy metal toxicity, Malnutrition
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, Fiber, High protein foods, Foods that support biliary function
Selecting this option will decrease: All known contraindicated food items, Foods that
congest the liver, Saturated fat foods

Low Blood Pressure (hypotension)


Possible predisposing factors: Endocrine hypo function, Vitamin B-1 deficiency, Food
allergy or sensitivity, Genetic predisposition, Iron anemia
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Sodium, Foods that support adrenal function
Selecting this option will decrease: All known contraindicated food items

Low Blood Sugar (hypoglycemia


Possible predisposing factors: Diets high in carbohydrates, Endocrine hypo function,
Liver/biliary dysfunction, Hypochlorhydria, Genetic predisposition, Pancreatitis, Immune
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DIET THERAPY PATIENT INTAKE FORMS

deficiency, Candidiasis, Excess caffeine intake, Hyperinsulinemia


Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Chromium, Foods that support pancreatic function
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods

Low Cholesterol (HDL)</name>


Possible predisposing factors: Immune dysfunction, Vegetarian diets, Endocrine hyper
function, Liver/biliary dysfunction, Manganese deficiency
Selecting this option will increase: Beneficial items specific to condition, Saturated fats,
Spicy food items, Essential fatty acids, High cholesterol foods, Foods that support liver
function
Selecting this option will decrease: All known contraindicated food items

Lungs
Highlights food items demonstrated to support lung health and function

Lung Problems (non-specific


Possible predisposing factors: Smoking, Air pollution, Allergies, Mucous, Parasites, Lack
of recovery from bronchitis
Selecting this option will increase: Beneficial items specific to condition, Foods that
support lung function, Hydration
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods

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DIET THERAPY PATIENT INTAKE FORMS

Lupus (systemic lupus erythematosis


Possible predisposing factors: Autoimmune disease, Viral infection
Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods, Mercury contaminated seafood

Lyme Disease
Possible predisposing factors: Tick bite
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, High protein foods, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items

Lymphatic
Highlights food items demonstrated to support lymphatic system health and function

Macular Degeneration
Possible predisposing factors: Prescription drug use, Atherosclerosis, Zinc deficiency,
Vitamin A, B-6 or C deficiency, Food/environmental sensitivity, Genetic predisposition,
Poor calcium metabolism, Bioflavonoid deficiency
Selecting this option will increase: Beneficial items specific to condition, Foods that
support eye health, Essential fatty acids, Hydration
Selecting this option will decrease: All known contraindicated food items
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DIET THERAPY PATIENT INTAKE FORMS

Male Infertility
Possible predisposing factors: Recent illness, Endocrine disorders, Varicoceles, Ulcer
medications, Genetic defects, Marijuana or cocaine use, History of venereal disease,
Urinary tract infections, Prostate hypertrophy, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Hydration, Arginine, Vitamin B-6, Zinc, Foods that support male sex organs
Selecting this option will decrease: All known contraindicated food items, Gluten,
Mercury contaminated seafood

Male Reproductive Organs


Highlights food items demonstrated to support testicular health and function. Reduces
consumption of alcohol and soft drinks which compromise testicular health.

Mammary Glands/Breasts
Highlights food items demonstrated to support mammary gland health and function.
Reduces consumption of items that compromise mammary health.

Manic Depression
Possible predisposing factors: Food allergy/sensitivity, Psychological disturbance,
Vitamin B-1 deficiency, Endocrine hypo function, Carbohydrate sensitivity (Syndrome X
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
triggers
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DIET THERAPY PATIENT INTAKE FORMS

Measles
Possible predisposing factors: Viral infection
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Fiber, Essential fatty acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Harmful fats,
Mercury contaminated seafood

Meniere's Disease
Possible predisposing factors: Spine, cranial or TMJ dysfunction, Hyper or hypotension,
Reduced circulation, Nerve damage, Infection with mucous congestion, Adrenal hypo or
hyper function, Vitamin B-1 deficiency, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Foods that
support hearing function
Selecting this option will decrease: All known contraindicated food items, Sodium,
Alcohol, Caffeine, High saturated fat foods, High glycemic index foods, Mucous
producing foods

Menopausal Hot Flashes


Possible predisposing factors: Hormonal imbalance, Iodine deficiency, Diets high in
refined carbohydrates, Alcohol or caffeine consumption, Excess hydrogenated fats and
oils, Obesity, Lack of exercise, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Phytoestrogens,
Phytosterols, Fiber, Hydration
Selecting this option will decrease: All known contraindicated food items, Sodium

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Menorrhagia
Possible predisposing factors: Tumors, cysts, endometriosis, Hormonal imbalance, Diets
high in refined carbohydrates, Lack of essential fatty acids, Anemia, Low body fat
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Food items that support ovaries, Phytoestrogens, High protein foods
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Harmful fats and proteins

Menstrual Cramps
Possible predisposing factors: Hormonal imbalance, Unstable blood sugar, Food allergy
or sensitivity, Diets high in refined carbohydrates, Calcium deficiency, Fatty acid
metabolism problems, Malabsorption
Selecting this option will increase: Beneficial items specific to condition, Fiber,
Hydration, Phytoestrogens, Bowel flora
Selecting this option will decrease: All known contraindicated food items, High sodium
food items, High saturated fat foods

Mercury Contaminated Foods (most common


Highlights in red print seafood items that research has shown commonly contain
unacceptable levels of mercury.

Mercury Toxicity
Possible predisposing factors: Dental fillings, Consumption of contaminated seafood, Use
of some medications, From mother at birth

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Hydration, Fiber, Foods that support liver function, Foods that support gall bladder
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood

Migraine Headache
Possible predisposing factors: Genetic predisposition, Food allergy or sensitivity,
Liver/biliary dysfunction, Hormonal imbalance, Thyroid dysfunction, Lactic acidosis,
Heavy metal toxicity, TMJ, cranial or spinal dysfunction, Reactive hypoglycemia,
Carbohydrate sensitivity (Syndrome X
Selecting this option will increase: Beneficial items specific to condition, High protein
foods
Selecting this option will decrease: All known contraindicated food items, common food
triggers, High glycemic index foods

Mitral Valve Prolapse


Possible predisposing factors: Genetic predisposition, Vitamin B-1 deficiency,
Magnesium deficiency, Scoliosis, Diets high in refined carbohydrates, Food allergy or
sensitivity
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Essential fatty acids, Foods that support heart function
Selecting this option will decrease: All known contraindicated food items

Mononucleosis
Possible predisposing factors: Viral infection, Contact with infected person

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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Fiber, Essential fatty acids, High protein foods,
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Mercury contaminated seafood

Mucous (allergy related


Possible predisposing factors: Food allergy or sensitivity, Environmental sensitivity,
Hypochlorhydria, Adrenal dysfunction, Immune dysfunction
Selecting this option will decrease: All known contraindicated food items, Most common
food allergens, Mucous producing food items

Mucous (respiratory/sinus
Possible predisposing factors: Food allergy or sensitivity, Environmental sensitivity,
Hypochlorhydria, Adrenal dysfunction, Immune dysfunction, Bronchial or sinus infection
Selecting this option will decrease: All known contraindicated food items, Most common
food allergens, Mucous producing food items

Multiple Sclerosis (MS


Possible predisposing factors: Mercury/heavy metal toxicity, Autoimmune disease,
Chemical toxicity, Genetic predisposition, Malnutrition, Stress, Viral infection, Food
allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Fiber
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Common food allergens, High saturated fat foods, Sodium
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Mumps
Possible predisposing factors: Viral infection, Exposure to infected person
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Anti-viral food items
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood

Muscles
Highlights food items demonstrated to support muscle health, function and development.

Muscular Dystrophy
Possible predisposing factors: Genetic predisposition, Heavy metal toxicity, Parasites
(amoebic, Bacterial or viral infection, Food allergy or sensitivity, Chemical toxicity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Fiber
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, Common food allergens, High saturated fat foods, Sodium

Myasthenia Gravis
Possible predisposing factors: Autoimmune dysfunction, Acetylcholine receptor
dysfunction, Ocular muscle fatigue
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Essential fatty acids, Foods that support eye function
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Selecting this option will decrease: All known contraindicated food items

Nausea
Possible predisposing factors: Biliary dysfunction, Dehydration, Diets high in refined
foods, Hypochlorhydria, Hyperchlorhydria, Pancreatic dysfunction, Constipation or
diarrhea, Thyroid or adrenal dysfunction, Ulcer, Infection
Selecting this option will increase: Beneficial items specific to condition, Foods that
support biliary function, Hydration
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods

Nails
Highlights food items demonstrated to support health and growth of finger and toenails.

Nervousness (anxiety
Possible predisposing factors: Reactive hypoglycemia, Vitamin B complex deficiency,
Calcium or magnesium deficiency, Psychological stress, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Refined
sugars, Caffeine, Harmful fats and proteins

Night Blindness (xerophthalmia


Possible predisposing factors: Vitamin A deficiency
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Selecting this option will increase: Beneficial items specific to condition, Carotenes,
Foods that support vision/eye health
Selecting this option will decrease: All known contraindicated food items

Non-food Items (synthetics


Highlights in red print manufactured consumable items that are not naturally occurring as
food

Non-Kosher Foods
This selection will eliminate all unacceptable foods based on numerous Orthodox nonsymbolic interpretations of the laws of kashrut. All foods not eliminated by this selection
must also meet kashrut standards in their source, preparation, and purity to be considered
Kosher.

Osteoarthritis
Possible predisposing factors: Genetic predisposition, Diets high in refined carbohydrate,
Excess consumption of alcohol, Excess consumption of caffeine, Thyroid and/or
parathyroid dysfunction, Excess use of antacids
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support bone health
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Nightshade family foods

Osteoporosis
Possible predisposing factors: Diets high in refined carbohydrates, Excess use of tobacco
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or alcohol, Obesity, Genetic predisposition, Hypochlorhydria, Endocrine dysfunction,


Lack of exercise, Chemotherapy, Corticosteroid use, Anticonvulsant medications
Selecting this option will increase: Beneficial items specific to condition, Calcium,
Vitamin D, Sulfur, High protein foods, Phytoestrogens
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Sodium, Sugars

Otitis Media (ear infection


Possible predisposing factors: Food allergy or sensitivity, Adrenal hypo function,
Bacterial or viral infection, Diets high in refined carbohydrates
Selecting this option will increase: Beneficial items specific to condition, Anti-microbial
food items, Foods that support ears/ear canal
Selecting this option will decrease: All known contraindicated food items, Common
allergens/food triggers, Mercury contaminated seafood, Mucous producing food items

Ovarian Dominant (Gonadal type


Distribution of patient's body fat is controlled primarily by ovarian hormones.

Pancreas
Highlights food items demonstrated to support pancreatic health and function. Reduces
consumption of items that adversely affect the pancreas.

Pancreatitis
Possible predisposing factors: Alcoholism, Digestive dysfunction, Type I or V
hyperlipoproteinemia, Diets high in refined carbohydrates, Food allergy or sensitivity,
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Parathyroid dysfunction, Psychological stress, Gall stones, Viral infection, Some


prescription medications
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Hydration
Selecting this option will decrease: All known contraindicated food items, High and
medium glycemic index foods, High fat foods

Parasites (general support


Possible predisposing factors: Parasitic infection
Selecting this option will increase: Beneficial items specific to condition, Anti-parasitic
food items, Sulfur
Selecting this option will decrease All known contraindicated food items, Mucous
producing food items, Foods that parasites thrive on, Mercury contaminated seafood

Parasthesia
Possible predisposing factors: Spinal, arm or leg joint dysfunction, B vitamin
deficiencies, Nerve degeneration, Magnesium deficiency, Diabetes
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids,
Selecting this option will decrease: All known contraindicated food items

Parasympathetic Dominant
Patient's metabolism is primarily being controlled by the parasympathetic branch of the
autonomic nervous system.

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Parkinson's Disease
Possible predisposing factors: Heavy metal toxicity, Chemical toxicity, Immune
dysfunction, B vitamin deficiencies
Selecting this option will increase: Beneficial items specific to condition, Phenyalanine,
High protein foods, Foods that support liver function, Foods that support lymphatic
system
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood

Peptic/Duodenal Ulcer
Possible predisposing factors: Excess or insufficient HCL production, Biliary or
pancreatic dysfunction, Bacterial infection, Pyloric or ileocecal valve dysfunction,
Chronic stress, Food allergy or sensitivity, Aspirin overuse, Overuse of some medications
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High fat content foods, Spicy foods

Periodontal Disease
Possible predisposing factors: Genetic predisposition, Poor dental hygiene, Diets high in
refined carbohydrates, Infection, Chronic dehydration
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, Foods that support dental health
Selecting this option will decrease: All known contraindicated food items

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Pesticide Contamination (non-organic foods


Highlights in red print food items that are commonly contaminated by pesticides. Note:
Organic foods do not normally contain these chemicals

Pneumonia
Possible predisposing factors: Bacterial or viral infection, Alcoholism, Environmental
allergy or sensitivity, Debilitating illness, Post gastro-intestinal surgery
Selecting this option will increase: Beneficial items specific to condition, Foods that
support lung function, Hydration, High protein foods
Selecting this option will decrease: All known contraindicated food items, Foods that
produce mucous, Mercury contaminated seafood

Phlebitis (vascular inflammation


Possible predisposing factors: Exogenous estrogen, Injury, Blood dyscrasias, Food
allergy or sensitivity, Chronic dehydration
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Hydration, Foods that support vascular function
Selecting this option will decrease: All known contraindicated food items, Sodium, High
saturated fat foods

Phobias
Possible predisposing factors: Reactive hypoglycemia, Vitamin B complex deficiency,
Calcium or magnesium deficiency, Insufficient vitamin A and E in diet, Food allergy or
sensitivity
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods
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Selecting this option will decrease: All known contraindicated food items, Refined
sugars, Caffeine, Harmful fats and proteins

Pitta-Kapha
(Fire/Water/Earth: subordinate) Highlights foods pertinent to Pitta-Kapha types.

Pituitary Dominant (Pituitary type)


Distribution of patient's body fat is controlled primarily by pituitary hormones.

Pituitary Dysfunction
Possible predisposing factors: Edema, Abnormal blood pressure variations, Insomnia,
Manganese or potassium deficiency, Vitamin E deficiency, Renal dysfunction, Food
allergy or sensitivity, Reduced TSH, Heavy metal toxicity, Diabetes or Syndrome X
Selecting this option will increase: Beneficial items specific to condition, High protein
foods
Selecting this option will decrease: All known contraindicated food items, Dairy fat and
protein

Pituitary Gland
Highlights food items demonstrated to support pituitary health and function. Reduces
long-chain fatty acids (borage oil) which are harmful to brain function.

PMS (premenstrual syndrome


Possible predisposing factors: Hormonal imbalance, Unstable blood sugar, Food allergy
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or sensitivity, Diets high in refined carbohydrates, Calcium deficiency, Fatty acid


metabolism problems, Malabsorption
Selecting this option will increase: Beneficial items specific to condition, Fiber,
Hydration, Phytoestrogens, Bowel flora
Selecting this option will decrease: All known contraindicated food items, High sodium
food items, High saturated fat foods

Polycythemia
Possible predisposing factors: Smoking, Chronic dehydration, Chronic lung dysfunction,
Genetic predisposition, Liver, biliary or spleen dysfunction
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Iron

Pregnancy (general support


Possible predisposing factors: Mother Nature and all her mysteries
Selecting this option will increase: Beneficial items specific to condition,
Docosahexaenoic acid, Zinc, Manganese, High protein foods, Folic acid
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, High vitamin A foods, Harmful fats

Pregnancy (with nausea


Possible predisposing factors: Hormonal imbalance, Dehydration, Drug toxicity,
Pancreatitis, Hypoglycemia, Molar pregnancy, Thyroid dysfunction, Inflammatory bowel
disorders
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DIET THERAPY PATIENT INTAKE FORMS

Selecting this option will increase: Beneficial items specific to condition,


Docosahexaenoic acid, Zinc, Manganese, High protein foods, Folic acid, Foods that
support biliary function
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, High vitamin A foods, Foods harmful to fetus and mother

Pregnancy (with yeast infection)


Possible predisposing factors: Hormonal imbalance
Selecting this option will increase: Beneficial items specific to condition, Anti-yeast food
items, Docosahexaenoic and caprylic acids, Zinc, Manganese, High protein foods, Folic
acid
Selecting this option will decrease: All known contraindicated food items, Refined
carbohydrates, Mercury contaminated seafood, High vitamin A foods, Harmful fats, High
glycemic index foods

Premenstrual Syndrome (PMS


Possible predisposing factors: Hormonal imbalance, Unstable blood sugar, Food allergy
or sensitivity, Diets high in refined carbohydrates, Calcium deficiency, Fatty acid
metabolism problems, Malabsorption
Selecting this option will increase: Beneficial items specific to condition, Fiber,
Hydration, Phytoestrogens, Bowel flora
Selecting this option will decrease: All known contraindicated food items, High sodium
food items, High saturated fat foods

Prostate
Highlights food items demonstrated to support prostate health and function.
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Prostatic Hyperplasia (benign


Possible predisposing factors: Food allergy or sensitivity, Urinary tract infection, History
of venereal disease, Obesity, Infrequent sexual activity, Lack of exercise, Genetic
predisposition, Normal hypertrophy of aging
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Lycopene, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
allergens, Mercury contaminated seafood

Psoriasis
Possible predisposing factors: Liver, biliary or pancreatic dysfunction, Psychological
stress, Adrenal hypo function, Genetic predisposition, Constipation, Sensitivity to soap,
bleach, etc, Food allergy or sensitivity, Colon toxicity
Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Essential fatty acids, Fiber, Foods that support healthy skin
Selecting this option will decrease: All known contraindicated food items, Arachidonic
acid, Saturated fats, Citrus fruits

Pulse Rate Decreased (bradycardia


Possible predisposing factors: Endocrine hypo function, Food allergy or sensitivity,
Vitamin B-1 deficiency, Genetic predisposition, Regular aerobic exercise
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support heart health, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
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allergens

Pulse Rate Increased (tachycardia


Possible predisposing factors: Endocrine hyper function, Potassium or magnesium
deficiency, Food allergy or sensitivity, Toxemia, Organic heart problem
Selecting this option will increase: Beneficial items specific to condition, Omega 3 fatty
acids, High protein foods
Selecting this option will decrease: All known contraindicated food items, Common food
triggers

Purpura Simplex
Possible predisposing factors: Portal/liver congestion, Standing or sitting for long periods,
Increased blood viscosity, Chronic dehydration, Anemia, Hormonal imbalance, Vitamin
C deficiency, Bioflavonoid deficiency
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Omega 3 fatty acids
Selecting this option will decrease: All known contraindicated food items, Foods that
cause venous congestion

Pyloric Valve Dysfunction


Possible predisposing factors: Food allergy or sensitivity, Parasites, Bowel flora
imbalance, Psychological stress, Post surgery traumatic stress
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Common food
triggers

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Radiation Therapy (support during


Possible predisposing factors: Radiotherapy treatment, Radiation exposure
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items

Raynaud's Disease
Possible predisposing factors: Artherosclerosis, Food allergy or sensitivity, Thyroid hypo
function, Vitamin B complex deficiency, Rheumatoid arthritis, Systemic Lupus (SLE
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Foods that support vascular system

Reduced Appetite
Possible predisposing factors: Intestinal parasites, Bowel flora imbalance, Hyper or
hypochlorhydria, Chronic conditions
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Fiber, Appetite stimulating spices
Selecting this option will decrease: All known contraindicated food items

Reduced Circulation
Possible predisposing factors: Anemia, Atherosclerosis, Thyroid hypo function, Adrenal
hypo function, B vitamin deficiency
Selecting this option will increase: Beneficial items specific to condition, Stimulatory
food items, Foods that support thyroid function, Foods that support adrenal function,
Foods that support circulation, Foods that increase hydration,
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Selecting this option will decrease: All known contraindicated food items, Foods that
suppress thyroid function
Selecting this option will decrease: All known contraindicated food items, Foods that
suppress thyroid function, Pungent food items

Renal Calculi (kidney stones


Possible predisposing factors: Low urine pH, Parathyroid dysfunction, Vitamin D
intoxication, Multiple myeloma, Diets high in refined carbohydrates, Genetic
predisposition, Infection, Chronic dehydration, Cystinuria, Diets high in oxalic acid
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber
Selecting this option will decrease: All known contraindicated food items, Oxalates,
Potassium, Phosphorus

Respiratory Infection
Possible predisposing factors: Acute: bacterial or viral infection, Chronic: iodine
deficiency, Diets high in refined carbohydrates, Adrenal insufficiency
Selecting this option will increase: Beneficial items specific to condition, Foods that
support lungs and bronchi, High protein foods
Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Mercury contaminated seafood

Rheumatoid Arthritis
Possible predisposing factors: Viral infection, Yeast infection, Parasites (especially
amoebic, Food or environmental sensitivities, Poor protein digestion, Heavy metal
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DIET THERAPY PATIENT INTAKE FORMS

toxicity (Hg, Cu common, Genetic predisposition


Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Gamma-linolenic acid
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, Common food allergens</id>

Ringing in Ears (tinnitus


Possible predisposing factors: Aberrant signals from brain, Medications (including
aspirin, Exposure to loud noises
Selecting this option will decrease: Common trigger foods

Ringworm (tinea
Possible predisposing factors: Fungal infection, Depressed immune function, Cancer,
HIV, Diabetes, Oral contraceptive use, Antibiotic use, Obesity, Persons who perspire
heavily
Selecting this option will increase: Beneficial items specific to condition, Anti-yeast food
items
Selecting this option will decrease: All known contraindicated food items, High
carbohydrate foods, Sugar foods

Rh negative
Patients with Rh factor negative blood have been found to have specific food allergies.

Schizophrenia
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Possible predisposing factors: Copper toxicity, Genetic predisposition, Complications


during birth, Head injury, Viral infection, Environmental toxicity, Magnesium deficiency,
Neurotransmitter imbalance, Prescription medication, Psychological trauma
Selecting this option will increase: Beneficial items specific to condition, Zinc, Vitamin
B-3, Vitamin C, Folic acid, High protein foods, Essential fatty acids, Fiber
Selecting this option will decrease: All known contraindicated food items, Copper, High
glycemic index foods

Sciatica
Possible predisposing factors: Carbohydrate dysmetabolism, Chronic dehydration, Spine
or pelvis misalignment
Selecting this option will increase: Beneficial items specific to condition, Food items that
support kidney function, Hydration
Selecting this option will decrease: All known contraindicated food items, High sugar
foods, High saturated fat foods

Scleroderma
Possible predisposing factors: Rheumatoid arthritis, Systemic Lupus (SLE, Thyroid hypo
function, Artherosclerosis, Food allergy or sensitivity, Vitamin B complex deficiencies
Selecting this option will increase: Beneficial items specific to condition, High protein
foods
Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Common food allergens, High glycemic index foods

Seborrhea
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Possible predisposing factors: Genetic predisposition, Biotin/vitamin A deficiency, Hair


follicle yeast infection, Climate, Stress/anxiety, Poor hygiene, Obesity, Parkinson's
disease, AIDS, Other skin disorders
Selecting this option will increase: Beneficial items specific to condition, Biotin, Foods
that support healthy skin/scalp
Selecting this option will decrease: All known contraindicated food items, Common food
triggers

Seizures (epilepsy)
Possible predisposing factors: Heavy metal toxicity, Intestinal parasites, Food allergy or
sensitivity, Reactive hypoglycemia, Manganese or magnesium deficiency, Vitamin B-6
deficiency, Head injury, Brain infection
Selecting this option will increase: Beneficial items specific to condition, Manganese,
Magnesium, Vitamin B-6, Foods that support nervous system
Selecting this option will decrease: All known contraindicated food items, All common
food triggers, Mercury contaminated seafood

Sex Drive Diminished (female)


Possible predisposing factors: Psychological stress or trauma, Hormonal imbalance,
Thyroid hypo function, Reactive hypoglycemia, Diets high in refined carbohydrates
Selecting this option will increase: Beneficial items specific to condition, Foods that
support female sex organs, Phytoestrogens, Hydration, High protein foods
Selecting this option will decrease: All known contraindicated food items

Sex Drive Diminished (male


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DIET THERAPY PATIENT INTAKE FORMS

Possible predisposing factors: Psychological disturbances, Hormonal imbalance, Mineral


deficiency, Food allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Zinc, Hydration, Foods that support male sex organs
Selecting this option will decrease: All known contraindicated food items

Shingles (Herpes Zoster


Possible predisposing factors: Varicella-zoster infection (Chicken pox, Stress, Cancer,
Chemotherapy, Spinal cord injury, Immunodeficiency
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, High protein foods, Essential fatty acids, Vitamin B-6
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood

Sinusitis (sinus infection


Possible predisposing factors: Bacterial or viral infection, Food or environmental
sensitivity, Sinus blockage, Constipation, Liver/biliary dysfunction
Selecting this option will increase: Beneficial items specific to condition, High protein
foods
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods, Mercury contaminated

Skin
Highlights food items demonstrated to support skin health and function. Reduces items
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DIET THERAPY PATIENT INTAKE FORMS

demonstrated to be harmful to skin health.

Skin Rashes
Possible predisposing factors: Sensitivity to casein and gluten, Excess sunlight exposure,
Digestive dysfunction, Diets high in fried food/hydrogenates, Calcium or magnesium
deficiency, Food allergy, Contact allergy or sensitivity
Selecting this option will increase: Beneficial items specific to condition, Food items that
support healthy skin
Selecting this option will decrease: All known contraindicated food items, Casein,
Gluten, Harmful fats

Slow Oxidation Dominant


Patient's metabolism is primarily being controlled by slow cellular oxidation.

Sperm Count Reduced


Possible predisposing factors: Food allergy or sensitivity, Alcohol consumption,
Endocrine disorders, Radiation exposure, Excessive heat, Recent illness, Testicular
injury, Varicoceles, Mumps
Selecting this option will increase: Beneficial items specific to condition, Arginine,
Vitamin B-6, Zinc, High protein foods, Foods that support male sex organs, Hydration
Selecting this option will decrease: All known contraindicated food items, Mercury
contaminated seafood, High gluten foods

Spine
Highlights food items demonstrated to support spinal health and function. Reduces items
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DIET THERAPY PATIENT INTAKE FORMS

that compromise skeletal health.

Spleen
Highlights food items demonstrated to support normal spleen health and function.

Sprue (celiac disease


Possible predisposing factors: Genetic predisposition, Psychological stress, Food allergy
or sensitivity, Parasites, Digestive dysfunction, Biliary/pancreatic insufficiency
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All gluten containing foods, Brassica family foods,
Beef, Dairy foods, Spicy trigger foods

Spurs (bone
Possible predisposing factors: Thyroid hypo function, Mineral insufficiency, Digestive
dysfunction
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High protein foods, Foods that support bone health
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High gluten foods

Stroke (recovery support


Possible predisposing factors: Capillary/vascular fragility, Hypertension, Atherosclerosis,
Blood stasis, Diets high in refined carbohydrates, Diets high in hydrogenated fats
Selecting this option will increase: Beneficial items specific to condition, Foods that
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support brain function, Foods that support vascular health


Selecting this option will decrease: All known contraindicated food items, High saturated
fat foods, Foods that elevate blood pressure

Sulfite Allergy-Sensitivity
Possible predisposing factors: Adrenal dysfunction, Immune dysfunction, Sulfite allergy
or sensitivity, Hypochlorhydria
Selecting this option will decrease: Sulfite containing food items

Sunburn
Possible predisposing factors: Excess exposure to sunlight, Inadequate UV light
protection
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, High water content foods
Selecting this option will decrease: All known contraindicated food items, Alcohol

Surgery (support for pre and post


Possible predisposing factors: Malnutrition, Dehydration, Consumption of unhealthy
items
Selecting this option will increase: Beneficial items specific to condition, Vitamin C,
Fiber, High protein foods, Bowel flora, Foods that support liver function
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods

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DIET THERAPY PATIENT INTAKE FORMS

Sympathetic Dominant
Patient's metabolism is primarily being controlled by the sympathetic branch of the
autonomic nervous system.

Syndrome-X (metabolic syndrome


Possible predisposing factors: Diets high in carbohydrates, Candida or fungal infections,
Adrenal hypo function, Digestive dysfunction, Vitamin B-1 deficiency, Magnesium or
potassium deficiency, Reactive hypoglycemia, Insulin autoimmunity
Selecting this option will increase: Beneficial items specific to condition, Chromium,
Zinc, High protein foods
Selecting this option will decrease: All known contraindicated food items, High glycemic
index foods, Medium glycemic index foods, Casein, High gluten foods

Systemic Lupus Erythematosis (SLE


Possible predisposing factors: Autoimmune disease, Viral infection
Selecting this option will increase: Beneficial items specific to condition, Sulfur,
Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods, Mercury contaminated seafood

Tachycardia
Possible predisposing factors: Endocrine hyper function, Potassium or magnesium
deficiency, Food allergy or sensitivity, Toxemia, Organic heart problem
Selecting this option will increase: Beneficial items specific to condition, Omega 3 fatty
acids, High protein foods
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Selecting this option will decrease: All known contraindicated food items, Common food
triggers

Tendonitis
Possible predisposing factors: Injury, Bone spurs, Tissue alkalinity, Inflammation from
repeated motion
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Foods that promote tissue regeneration, Foods that support tendon health
Selecting this option will decrease: All known contraindicated food items, High gluten
foods, Casein, Caffeine, Refined sugars

Thrombophlebitis
Possible predisposing factors: Vascular injury (often minor, Abnormal clotting tendency,
Poor circulation, Behcet's syndrome, Cancer (some types, Recent childbirth, Surgery,
Birth control pills, Prolonged bed rest
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Foods that support vascular health, Hydration
Selecting this option will decrease: All known contraindicated food items, Vitamin K,
Foods that cause vascular congestion

Thrush (oral yeast/fungus


Possible predisposing factors: Prolonged antibiotic use, Hormone replacement therapy,
Adrenal dysfunction, High carbohydrate diets, Digestive dysfunction, Bowel flora
imbalance, Prolonged use of antacids, Use of prescription acid blockers, Hypochlorhydria
Selecting this option will increase: Beneficial items specific to condition, Anti-yeast food
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items
Selecting this option will decrease: All known contraindicated food items, High
carbohydrate foods, High sugar foods

Thymus
Highlights food items demonstrated to support thymus health and function. Reduces
consumption of items known to compromise thymus function

Thyroid
Highlights food items demonstrated to support thyroid health and function. Reduces items
that compromise thyroid function.

Thyroid Dominant (Thyroid type)


Distribution of patient's body fat is controlled primarily by thyroid hormones.

Thyroid Hyper-function (hyperthyroid


Possible predisposing factors: Auto-immune disorder, Infection, Thyroid inflammation,
Space occupying thyroid lesion, Food allergy or sensitivity, Hormonal imbalance
Selecting this option will increase: Beneficial items specific to condition, Brassica family
foods, High protein foods
Selecting this option will decrease: All known contraindicated food items, Iodine,
Thyroid stimulating foods, Common food triggers

Thyroid Hypo-function (hypothyroid


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Possible predisposing factors: Iodine insufficiency, Fatty acid deficiency, Protein


deficiency, Hormonal imbalance, Drinking chlorinated water, High carbohydrate diets
Selecting this option will increase: Beneficial items specific to condition, Iodine, Foods
that support thyroid function
Selecting this option will decrease: All known contraindicated food items, Foods that
suppress thyroid function

Tic Douloureux (trigeminal neuralgia


Possible predisposing factors: Viral infection of facial nerves, Trauma, Inflammation of
facial or cranial nerves
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Hydration, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Caffeine

Tinea (ringworm
Possible predisposing factors: Fungal infection, Depressed immune function, Cancer,
HIV, Diabetes, Oral contraceptive use, Antibiotic use, Obesity, Persons who perspire
heavily
Selecting this option will increase: Beneficial items specific to condition, Anti-yeast food
items
Selecting this option will decrease: All known contraindicated food items, High
carbohydrate foods, High sugar foods

Tinnitus
Possible predisposing factors: Aberrant signals from brain, Medications (including
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aspirin, Exposure to loud noises


Selecting this option will decrease: Common trigger foods

Tooth Decay
Possible predisposing factors: Oral bacterial disease, Poor oral hygiene, Diets high in
refined carbohydrates, Chronic acidic saliva
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
food items, Food items that support dental health
Selecting this option will decrease: All known contraindicated food items, Refined sugars

Trigeminal Neuralgia (tic douloureux)


Possible predisposing factors: Viral infection of facial nerves, Trauma, Inflammation of
facial or cranial nerves
Selecting this option will increase: Beneficial items specific to condition, High protein
foods, Hydration, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Caffeine

Triglycerides Elevated
Possible predisposing factors: Alcohol consumption, Diets high in sugars, Diets high in
saturated fats, Carbohydrate sensitivity (Syndrome X
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Fiber
Selecting this option will decrease: All known contraindicated food items, High sugar
food items, High saturated fat foods
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DIET THERAPY PATIENT INTAKE FORMS

Tuberculosis (TB
Possible predisposing factors: Mycobacterium tuberculosis exposure, Overcrowded living
conditions, Poor home ventilation, Contaminated foods, Unpasteurized milk
Selecting this option will increase: Beneficial items specific to condition, Bowel flora,
High protein foods, Anti-bacterial food items, Essential fatty acids, Foods that support
ling function
Selecting this option will decrease: All known contraindicated food items, Foods that
produce mucous

Type A1
Patient has blood type A1.

Type A2B
Patient has blood type A2B

Type A Lectins
Highlights food items that have lectins specific to blood type A.
Lectin reactions are especially significant in raw food diets (95% of lectins are destroyed
by cooking

Type O, A, B, AB, Lectins


Lectin reactions are especially significant in raw food diets, 95 % of lectins are destroyed
by cooking.

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Type O Lectins
Highlights food items that have lectins specific to blood type O.

Ulcer (peptic/duodenal
Possible predisposing factors: Excess or insufficient HCL production, Biliary or
pancreatic dysfunction, Bacterial infection, Pyloric or ileocecal valve dysfunction,
Chronic stress, Food allergy or sensitivity, Aspirin overuse, Overuse of some medications
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, Citrus fruits,
High fat content foods, Spicy foods

Ulcerative Colitis
Possible predisposing factors: Psychological stress, Food allergy or sensitivity, Infection,
Genetic predisposition, Parasites, Hypochlorhydria, Bowel flora imbalance, Biliary or
pancreatic insufficiency
Selecting this option will increase: Beneficial items specific to condition, Fiber, Vitamin
K
Selecting this option will decrease: All known contraindicated food items, Common food
triggers, High fat food items

Upper Respiratory Infection


Possible predisposing factors: Acute: bacterial or viral infection, Chronic: iodine
deficiency, Diets high in refined carbohydrates, Adrenal insufficiency
Selecting this option will increase: Beneficial items specific to condition, Foods that
support lungs and bronchi, High protein foods
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Selecting this option will decrease: All known contraindicated food items, Mucous
producing food items, Mercury contaminated seafood

Upset Stomach (indigestion


Possible predisposing factors: Food allergy or intolerance, Hypochlorhydria, Digestive
enzyme deficiency, Peptic ulcer, Eating too fast, Stomach or intestine disorders
Selecting this option will increase: Beneficial items specific to condition, Foods that
support digestion, Foods that support biliary function, Fiber
Selecting this option will decrease: All known contraindicated food items, Common
trigger foods

Urinary Tract Infection (UTI)


Possible predisposing factors: Poor personal hygiene, Nylon underwear, Sexually
transmitted infection, Sensitivity to toilet paper, tampons, etc
Selecting this option will increase: Beneficial items specific to condition, Anti-bacterial
foods, Hydration, Foods that support bladder function, Foods that support kidney function
Selecting this option will decrease: All known contraindicated food items, Mucous
producing foods, Mercury contaminated seafood

Uterine Fibroids
Possible predisposing factors: Genetic predisposition, Ethnic background, Estrogen
intolerance
Selecting this option will increase: Beneficial items specific to condition, Foods that
support liver function, High protein foods, Hydration, Essential fatty acids

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Selecting this option will decrease: All known contraindicated food items, Sodium, High
saturated fat foods

Urticaria (hives)
Possible predisposing factors: Food allergy or sensitivity, Contact with triggering
chemicals, Viral infection, Yeast infection, Antibiotic use, Drug use or abuse
Selecting this option will increase: Beneficial items specific to condition
Selecting this option will decrease: All known contraindicated food items, All known
common food triggers

Varicose Veins
Possible predisposing factors: Prolonged standing or sitting, Pregnancy, Heavy lifting,
Constipation, Lack of exercise, Liver disease, Vitamin C/bioflavonoid deficiency, Birth
control pills, Genetic predisposition, Heart failure
Selecting this option will increase: Beneficial items specific to condition, Hydration,
Fiber, Essential fatty acids, Foods that support vascular function
Selecting this option will decrease: All known contraindicated food items, Alcohol, High
saturated fat foods

Vascular Inflammation (phlebitis


Possible predisposing factors: Exogenous estrogen, Injury, Blood dyscrasias, Food
allergy or sensitivity, Chronic dehydration
Selecting this option will increase: Beneficial items specific to condition, Essential fatty
acids, Hydration, Foods that support vascular function
Selecting this option will decrease: All known contraindicated food items, Sodium, High
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saturated fat foods

Vegan
Choosing this selection will eliminate all animal source food items.

Veins/Arteries
Highlights food items demonstrated to support vascular health and function. Reduces
items that compromise vascular health.

Vertigo
Possible predisposing factors: Food allergy or sensitivity, Blood pressure alterations,
Viral infection/fever, Some prescription drugs, Oxygen insufficiency, Neurological
disease, Nutritional deficiencies, Ear infections, Ear canal blockage, Anemia
Selecting this option will increase: Beneficial items specific to condition, Foods that
support inner ear health
Selecting this option will decrease: All known contraindicated food items, Sodium,
Alcohol, Caffeine

Viral Infection
Possible predisposing factors: Contact with infected person, Oxidative stress,
Acid/alkaline imbalance
Selecting this option will increase: Beneficial items specific to condition, Anti-viral food
items, Fiber, High protein foods, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, High saturated
fat food items, Mercury contaminated seafood
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DIET THERAPY PATIENT INTAKE FORMS

Vitiligo
Possible predisposing factors: Genetic predisposition, Autoimmune disorder, Thyroid or
adrenal malfunction, Trauma to skin, Chemical toxicity, Stress, Anemia (B-12 or folic
acid, Diabetes, Calcium or magnesium deficiency, Essential fatty acid deficiency
Selecting this option will increase: Beneficial items specific to condition, Para-amino
benzoic acid, Carotenes, Vitamin C, Magnesium
Selecting this option will decrease: Alcohol, Citrus fruits

Water Retention (edema


Possible predisposing factors: Cardiac/renal dysfunction, Food allergy or sensitivity,
Adrenal hypo function, Tissue inflammation, B vitamin deficiency, Ascites
Selecting this option will increase: Beneficial items specific to condition, Foods that
support kidney function, Essential fatty acids
Selecting this option will decrease: All known contraindicated food items, Sodium,
Common food allergens, Red meat

Wilson's Disease (copper toxicity


Possible predisposing factors: Genetic predisposition, Elevated urine kryptopyrole, Zinc
deficiency, Vegetarian diet, Copper water supply pipes, Chronic infection, Chronic
elevated estrogen, Adrenal insufficiency
Selecting this option will increase: Beneficial items specific to condition, Sulfur, Zinc,
Vitamin C, Hydration, Fiber, Essential fatty acids, Foods that support liver function, High
protein foods
Selecting this option will decrease: All known contraindicated food items, Copper intake
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DIET THERAPY PATIENT INTAKE FORMS

Xerophthalmia (night blindness


Possible predisposing factors: Vitamin A deficiency
Selecting this option will increase: Beneficial items specific to condition, Carotenes,
Foods that support vision/eye health
Selecting this option will decrease: All known contraindicated food items

Yeast Infections (including candidiasis


Possible predisposing factors: Prolonged antibiotic use, Hormone replacement therapy,
Adrenal dysfunction, High carbohydrate diets, Digestive dysfunction, Bowel flora
imbalance
Selecting this option will increase: Beneficial items specific to condition, Anti-yeast food
items
Selecting this option will decrease: All known contraindicated food items, High
carbohydrate foods, High sugar foods

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