Meal Plan Client Intake Form

GOALS
Do you have a specific weight goal you’re trying to achieve?
(Yes/No - If Yes, specify)
What are your primary health goals?
(e.g., weight loss, muscle gain, maintain current weight, improve energy, manage a health condition)
What motivates you to make changes to your diet?
(e.g., fitness goals, health conditions, upcoming events)

Dietary perferences
What type of meal plan are you interested in?
(e.g., balanced, low-carb, keto, vegan, vegetarian, gluten-free, paleo)
Do you follow any specific diet or have any dietary restrictions?
(e.g., dairy-free, gluten-free, nut-free, kosher, halal)
What are your favorite types of foods or cuisines?
(e.g., Italian, Mexican, Asian)
Are there any foods you dislike or prefer to avoid?
Do you have any allergies or intolerances?
Are there specific ingredients you would like to include or exclude from your meal plan?

Meal Preferences and Lifestyle
How many meals do you typically eat in a day?
(Breakfast, Lunch, Dinner, Snacks)
What time do you usually have your meals?
(Approximate times for breakfast, lunch, dinner)
How would you describe your current activity level?
(e.g., sedentary, lightly active, moderately active, very active)
Do you have any current health conditions that we should be aware of?
(e.g., Diabetes, Thyroid, Pregnancy, hypertension, digestive issues)
Are you currently on any medication?
Please list ALL supplements your are taking:
Do you have any specific nutrition concerns or conditions?
(e.g., low energy, digestive issues, high cholesterol)
How many hours of sleep do you get each night?
How much caffeine do you consume daily on average or on a typical work day?
Which of the following options best describes your activity level?
Which of the following options best describes your stress level?
[Women only] Do you have a regular menstrual cycle? And are you using any form of contraception?

Current Eating Habits
What does a typical day of eating look like for you?
Please provide a sample of your daily meals and snacks)
Do you currently prepare most of your meals at home or eat out often?
How often do you consume snacks or beverages between meals?
(e.g., tea, coffee, soda, smoothies)
How would you rate your current eating habits?
What level of cooking skills do you have?
(Beginner, Intermediate, Advanced, Live in help)
Do you drink alcohol? If yes, how often?
What type of alcohol do you drink and how much?
Calculate in glasses per week

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