Nutrition Intake Assessment

Nutrition Intake Assessment Form
Please answer all questions to the best of your ability.
Please talk with your provider if you have questions about this form.
I'm filling this form out for...*
Person Completing the Form

First NameLast Name
Relationship to Client
Client Full Name*

First NameLast Name
Client Preferred Name
If different from legal name
Client Date of Birth*

MonthDayYear
Client preferred Email*
example@example.com
Birth Sex*
Gender Identity
For example: Female, Male, Nonbinary, Transgender, etc.
Pronoun
For example: She, He, They, Etc.
How did you hear about our practice?
We'd love to thank the person who referred you to us if you want to provide their name & email.
Name & Email would be awesome!
Medical History and Concerns
Medications currently prescribed and taking
Please include dosage and frequency
Nutritional Supplements Currently Taking
Please include any herbal or homeopathic supplements
Do you have current or past Gastrointestinal concerns?

NoYesNot Sure
Provide a description of your GI concerns or questions:
Medical Treatments or Concerns (Past & Present)
Include approximate dates of treatments and details about your concerns
Do any of your relatives have a Chronic Disease?

YesNoNot Sure
List family members and diseases:
Age of 1st Menstrual Cycle
Example: 13
Date of the first day of your last cycle:

MonthDayYear
Date
Does your menstrual cycle happen every month?

YesNoSometimes
Please describe the pattern of your cycle.
Include when it stopped if you are currently not menstruating.
Number of previous pregnancies:
Coordination of Care
Please check any other Healthcare Providers you are currently seeing

NonePsychiatristCounselorPrimary Care ProviderDietitianEndocrinologistGynocologistGastroenterologistOrthopedistCardiologistOther
Please consider filling out a Release of Information for each provider so we can coordinate care as needed. You can click on this link and complete the Release now or save this link address to complete it later.

https://form.jotform.com/discoverycounseling/release-of-information
If there is anyone else who is part of your care team or needs to be informed about your counseling, please list them here & complete a Release of Information for them.
Substance Use

Please share the frequency of any Substance Use:

	Never	Rarely	Sometimes	Weekly	Daily
Caffeine
Alcohol
Nicotine
Marijuana
Recreational Prescription Drug Use
"Street" drug use

Any additional Substance Use Information?
Past use, quit date(s), details of use, etc.?
Food & Body Concerns

How often you struggle with any of these food & body related behaviors?

	Never	Rarely	Sometimes	Weekly	Daily
Dieting & Restricted eating
Body Checking & Weight monitoring
Purging
Pills or supplements for weight control
Extreme or intense exercise
Avoiding things due to food or body struggles

Any additional details about food or body concerns?
Past use, quit date(s), details of use, etc.?
Treatment History
Have you had Individual Nutrition Counseling in the past?

YesNo
Share a brief description of past counseling experience
Dates, locations, provider traits you liked or disliked, etc.
Have you had Individual Mental Health Counseling in the past?

YesNo
Share a brief description of past counseling experience
Dates, locations, provider traits you liked or disliked, etc.
Have you had Intensive Treatment in the past (inpatient, PHP, IOP, etc.)?

YesNo
Share a brief description of past intensive treatment experience
Dates, treatment programs, aspects your like or disliked, etc.
Has anyone in your family been diagnosed or been treated for mental health concerns?

YesNoNot Sure
Share a brief description of mental health challenges in your family.
Family member, diagnosis or treatment, etc.
Goals
List 3 Goals for Nutrition Counseling:
Goals can be anything you want to change, enhance or accomplish.
Specific food behaviors you'd like to address:
List 3 Personal Strengths:
Strengths can be internal or external to you.
List 3 Limitations that would keep you from reaching your Nutrition Counseling goals:
Limitations can be internal or external.
If there is anything you haven't shared yet and you'd like to include it, please share it here:

Nutrition Intake Assessment Form