for your Appointment
Daily Food Journal
Physician Referral Form
Click on the link above to download your food journal. This will be useful for your individual appointment. Plan to complete at least three days worth of food journals prior to your appointment. You can either print it out and hand-write your intake or type it and email it to your RD the day before your appointment.
You will need to complete this initial form prior to your first appointment. Doing this will help save time during your appointment and will allow your RD to help tailor your appointment to meet not only your medical needs but also your personal needs.
Your doctor may need to complete this referral for medical nutrition therapy in order for your insurance company to provide reimbursment. Please print this out and bring to your next doctors appointment and make sure you bring this completed form to your appointment with the registered dietitian.