Holistic Nutrition Consultation Questionnaire

Holistic Nutrition Consultation Questionnaire — Form Fields

This healthcare template includes 13 fields. Pre-consultation questionnaire for holistic nutrition and dietary wellness assessments. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email (email, required)
• Phone Number (text, required)
• Date of Birth (text, required)
• Primary Health Goal (dropdown selection, required) — options: Weight Loss, Weight Gain, Gut Health, Energy Levels, Hormone Balance, Inflammation Reduction, Sports Performance, General Wellness
• Current Dietary Style (checkboxes, optional) — options: Standard American, Vegetarian, Vegan, Paleo, Keto, Mediterranean, Gluten-Free, Dairy-Free
• Meals Per Day (dropdown selection, required) — options: 1-2, 3, 4-5, 6+, Irregular
• Digestive Symptoms (checkboxes, optional) — options: Bloating, Gas, Constipation, Diarrhea, Acid Reflux, Nausea, Food Sensitivities, None
• Water Intake (glasses/day) (dropdown selection, required) — options: 1-2, 3-4, 5-6, 7-8, 8+
• Sleep Quality (dropdown selection, required) — options: Excellent, Good, Fair, Poor
• Known Food Allergies (text, optional)
• Current Supplements (long text, optional)
• Health Concerns and Goals (long text, required)