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
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?
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?

Other
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?
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
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