Nutrition Client Intake Form Template
Dietitians use this form to learn about a client's nutrition goals, eating habits, allergies, health conditions, activity, and typical daily meals.
When to use it
- Before a client's first nutrition appointment
- When updating a returning client's food and health history
- Before creating a personalized meal or nutrition plan
- For remote nutrition consultations
What it asks
- What is your name?
- What is your email address?
- What is your phone number?
- What are your nutrition goals?
- How would you describe your eating habits?
- Do you have any food allergies?
- Do you have any food intolerances?
- Do you have any medical conditions relevant to your nutrition?
- What kind of physical activity do you usually do?
- What do you typically eat and drink in a day?
Why it should be encrypted
Food allergies, medical conditions, and eating habits can be personal health information. Keep these answers private from anyone who isn't involved in the client's care.
Tips
- Invite clients to describe allergies and intolerances clearly, including known reactions.
- Add a question about medications or supplements if relevant to your practice.
- Ask clients to include snacks, drinks, and approximate portions in their typical-day response.