7 Day Food/Substance Journal


The 7-day Food and Substance Journal allows us to evaluate what might be causing a reaction in your body or your child’s body.  Please list all food & drink and the things that you use ON your body or your child's body.  Essentially everything you or your child will touch, taste, and smell. 

In addition to obvious strong allergic reactions, sensitivity to particular foods or chemicals can create a wide variety of symptoms including: fuzzy thinking, generalized gut sensitivity, behavior changes, mood changes, reading and writing difficulties, and many others.  These reactions may be caused by undiagnosed allergies

Using Occipital Drop checks, we will evaluate whether it is a temporary or permanent reaction and if an Allergy Clearing adjustment can be made to help clear out the reactions.  We encourage you to be as specific as possible with what you put in your mouth and on your body.  Include drinks, gum, mints, toothpaste, vitamins and supplements, etc.  Parents filling this out for their child should be aware of items that they are putting on themselves and then touching their child, i.e. perfume, lotions, aftershave, etc.  Please also list any air fresheners and cleaning supplies that may be found in your home. If you are having something like a casserole, list the ingredients you put in it rather than just listing "casserole". If it is a packaged food, we do not need the ingredient list. If it registers as an issue, it can be looked at in depth to see if it is a particular ingredient within that product.

There is no judgment in this evaluation.  What we mean by that is, we don't care if you eat cookies and milk all day.  We just need to know WHAT you are REALLY eating to find out what may be causing the problems.  Based on the evaluation, general suggestions to improve your overall nutrition will be included with your specific evaluation.*

The charge for this service is $50.00 which is due upon receiving this packet. Please return your completed packet to the office for evaluationvisit.  If you prefer to record electronically, you can submit your completed food and substance journal via e-mail to DrRoss@RechargeYourLife.com.

*Nutritional Informed Consent

According to the Federal Food, Drug, and Cosmetic Act, as amended, Section 201(g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.”

A Vitamin is not a drug, NEITHER is a Mineral, Trace Element, Amino Acid, Herb, or Homeopathic Remedy. Although these may have an effect on any disease process or symptoms, this does not mean that it can be misrepresented, or be classified as a drug by anyone. Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as a primary treatment and/or therapy for any disease or particular bodily symptom.

Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of foods in the patient’s diet in order to supply good nutrition supporting the physiological and biomechanical processes of the human body. Nutritional advice and nutritional intake may also enhance the stabilization of chiropractic adjustments.



Name:_________________________ E-mail:_______________________                                   


Day 1

Items put IN the body                                                Items put ON the body











Day 2

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Day 3

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Day 4

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Day 5

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Day 6

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Day 7

Items put IN the body                                                Items put ON the body












Please list any other products you use/consume frequently but maybe less than once a week (i.e. not in the last 7 days):






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