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Templates→Healthcare→Nutrition Counseling Intake Form

Nutrition Counseling Intake Form

Collect dietary history, health goals, and lifestyle information before a nutrition counseling session. Helps dietitians create personalized nutrition plans.

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Nutrition Counseling Intake Form

Tell us about your eating habits and health goals so we can tailor a nutrition plan to your needs.

Full Name*

Primary Health Goal(s) (select all that apply)*

Weight lossWeight gain / muscle buildingManage a health condition (diabetes, heart disease, etc.)Improve energy levelsGeneral healthy eating

How would you describe your current diet?*

Omnivore (eat everything)VegetarianVeganGluten-freeOther

Food Allergies or Intolerances

How many meals do you typically eat per day?

How often do you cook meals at home?

Most mealsAbout half the timeRarely

Describe a Typical Day of Eating

Medical Conditions Affecting Diet

Template Details

CategoryHealthcare

IndustryHealthcare

Fields8

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healthcarenutritiondietitiandietary assessmentwellness

Nutrition Counseling Intake Form - Free Healthcare Template | ZenBuild | ZenBuild