Dietary Survey Questionnaire

4 Steps in Healing the Gut

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Our diets are probably the most important controllable factor when it comes to our health. Unfortunately, changing our diets can be the most difficult thing to do. A lifetime of habits seem to control us and it often takes the discipline of a Tibetan Monk to make changes that stick.

One of the best ways to analyze dietary influence is to simply take a closer look. This survey (below) will help us do just that. Dr. Conners often recommends further Functional tests to fully measure sensitivities, but let's start with just the survey.

If you've been directed to this page by Dr. Conners or one our our Practitioners, please complete the on-line form below and hit SUBMIT at the end for us to review it. Thanks!

Dietary - Daily Record of Food Intake

Full Name*
Day 1 - Date:*
Morning-Noon - List Specific Foods and Approximate Amount and Type (e.g.: "2 eggs, 2 pieces gluten-free toast, jelly")
Noon-4:00ish - List Specific Foods and Approximate Amount and Type
4:00-bedtime - List Specific Foods and Approximate Amount and Type
Day 2 - Date:*
Morning-Noon - List Specific Foods and Approximate Amount and Type (e.g.: "2 eggs, 2 pieces gluten-free toast, jelly")
Noon-4:00ish - List Specific Foods and Approximate Amount and Type
4:00-bedtime - List Specific Foods and Approximate Amount and Type
Day 3 - Date:*
Morning-Noon - List Specific Foods and Approximate Amount and Type (e.g.: "2 eggs, 2 pieces gluten-free toast, jelly")
Noon-4:00ish - List Specific Foods and Approximate Amount and Type
4:00-bedtime - List Specific Foods and Approximate Amount and Type
Please Explain Your Average Amount of Sleep You Are Getting Each Night As Well As The Quality Of Your Sleep:
Please Explain If You Are Having Normal, Daily Bowel Movements:*

Have Questions?

That’s okay, we’re here to guide you on your journey.

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Please be advised that the coaches and other staff members at Conners Clinic are NOT licensed to practice medicine in Minnesota; DO NOT practice medicine; DO NOT prescribe, give, or administer any drug or medicine; DO NOT offer or undertake to prevent, diagnose, correct, or treat any disease, illness, pain, wound, fracture, infirmity, deformity or defect; and DO NOT offer to undertake to perform any form of surgery or hypnosis.

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Dietary Survey Questionnaire

More Videos on Diet and GUT Health:

Dietary - Daily Record of Food Intake

Have Questions?

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