Nutrition Intake Form

Nutrition: New Client Intake Form

Please complete this form before your initial consultation. Email marjie@virtafitness.com if you have any questions. Thanks!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Preferred Method of Contact

HomeWorkCellEmail
Home Phone #

Area CodePhone Number
Work Phone #

Area CodePhone Number
Cell Phone #

Area CodePhone Number
Email*

Confirmation Emailexample@example.com
Address (if you would like materials mailed)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How would you prefer to speak with the dietitian during your consultation?*

Video chatOver the phone
How did you find out about VirtaFitness?*
Client history
Height*
Inches
Current weight*
Pounds
Goal weight (if different than current weight)
Pounds
Recent weight history: Have you gained/lost/maintained weight recently?
Are you currently pregnant or breast-feeding?*

NeitherPregnantBreastfeedingOther
Occupation
I would like to see a dietitian because...*
If I could change 3 things about my health and/or nutrition habits, they would be:*
How often do you prepare your own meals? (not including microwaveable/frozen meals) *
ex) Always, most of the time, rarely, never
How often do you consume alcohol? *
Have you tried any diets/special eating patterns in the past? If so, what have you tried?*
Do you currently follow any diet, including vegetarian/vegan, keto, intermittent fasting, etc.?*
Have you ever/do you currently "track" your intake using a journal or an app (like MyFitnessPal)? If so, what do you use?*
I feel that my biggest barrier(s) to achieving my nutrition goals is/are:*
Describe your current level of exercise or physical activity:*
About how much sleep do you typically get each night?*

Less than 4 hours4-6 hours7-9 hoursMore than 9 hours
Please list any medical diagnoses/problems you have had, including (but not limited to): Diabetes, high/low blood sugar, sleep apnea, heart disease, heart attack, stroke, high cholesterol/triglycerides, kidney disease, liver disease, cancer, etc. *
Have you had routine blood labs performed in the past 12 months?(i.e., cholesterol, glucose levels, etc.) *IF SO, please provide them by email to the RD if possible*

YesNoI don't know
Please list all medications and supplements you currently take, or type N/A:*
Please list all food allergies, or type N/A: *
Date*

YearMonthDay
Date
To get a better idea of your typical eating habits, I request that you complete a 3-day food log and email it to me at least 24 hours before your initial consultation. The form and instructions have been sent to your email. Please try to include 2 weekdays and 1 weekend day for a more accurate record.
Note: If you would like a consultation for weight loss, it is strongly recommended that you provide the dietitian with your current waist, upper arm, and thigh measurements. These will be used as a baseline for tracking your progress. Instructions on how to take these measurements have been sent to your email.
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Nutrition: New Client Intake Form

Client history