Nutrition Screening Form
Thank you for taking the time to complete this form. Your answers will help us assess your nutritional status and provide appropriate care.
Personal Information
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Male
Female
Other
Weight
Height
Contact Information
Email Address
example@example.com
Nutritional Habits
How many meals do you eat per day?
1
2
3
4
5 or more
How often do you consume fruits and vegetables?
Rarely
Occasionally
Daily
Other
Do you have any dietary restrictions or allergies?
Do you take any dietary supplements?
Yes
No
Other
If yes, please list the supplements you take:
Favorite meals and/or snacks?
Is there any food you may dislike?
Physical Activity
How often do you engage in physical activity?
Rarely
Occasionally
Daily
Other
Do you have any medical conditions that affect your dietary needs?
Are you currently on a special diet prescribed by a healthcare professional?
Yes
No
Other
If yes, please specify the diet and the reason for the prescription:
Family Medical History
Are there any family members with a history of nutritional disorders or chronic diseases?
Additional Comments
What is the nutritional goal you are trying to achieve?
Submit
Should be Empty: