Nutrition Client Intake Form

Nutrition Client Intake Form
Personal Information
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Emergency Contact
Health & Medical History
Height (cm)
Weight (kg)
Do you have any medical conditions? (eg: diabetes, hypertension, thyroid issues) Please list:
Do you have any allergies or intolerances? Please list:
Are you currently taking any medications or supplements? Please list:
Do you have any family history of chronic diseases? (eg: heart disease, diabetes) Please list:
Do you have any physical limitations or injuries? Please describe:
Dietary Habits
Do you have any dietary restrictions? (vegetarian, vegan, gluten free) Please list:
How many meals do you typically eat in a day?
Do you snack between meals? If yes, what types of snacks do you usually have?
Do you have any food cravings? If yes, Please list:
Do you have any aversions to certain foods? Please list:
Describe a typical day's meals and snacks:
Do you consume alcohol? If yes, how often and how much?
Do you drink coffee or tea? How many cups per day?
Lifestyle and Physical Activity
Describe your occupation (eg: desk job, active job)
Do you exercise often? If yes, how many times per week and what type of exercise?
Do you have any hobbies or activities that keep you active? Please describe:
How would you rate your stress levels? (1-10)
How many hours of sleep do you get on average per night?
Do you have any trouble sleeping? If yes, please describe:
Goals and Expectations
What are your primary health and nutrition goals?
What motivates you to achieve these goals?
Have you worked with a Nutritionist or Dietician before? If yes, what was your experience like?
Are there any specific challenges you face with your current diet and lifestyle?
Mental and Emotional Health
Do you have a history of eating disorders or disordered eating habits? If yes, please describe:
Do you experience any of the following? (check all that apply)

Binge EatingEmotional EatingRestrictive EatingFear of Certain FoodsObsessive thoughts about Food or Body Image
Have you sought professional help for any mental health concerns? If yes, please describe:
How would you describe your relationship with food?
What are your top 3 health and nutrition goals?
What challenges do you feel may prevent you from achieving these goals?
What motivates you to improve your health right now?
Additional Information
Is there any other information you think is important for me to know?
Do you have any specific questions or concerns you would like to address during our session?
Disclaimer

Purpose of Information Collection:

The information collected in this intake form is intended solely for the purpose of providing personalised nutrition advice and creating a tailored nutrition plan. This information will be kept confidential and used exclusively by the nutritionist.

Not a Substitute for Medical Advice:

The services provided by the nutritionist are not a substitute for medical advice, diagnosis, or treatment. It is essential to consult with your physician or healthcare provider before making any changes to your diet, exercise, or medication regimen. The nutritionist does not provide medical advice, diagnosis, or treatment.

Accuracy of Information:

The accuracy of the information provided by the client is crucial for developing an effective nutrition plan. The client is responsible for providing accurate and complete information. The nutritionist is not liable for any consequences arising from inaccurate or incomplete information provided by the client.

Voluntary Participation:

Participation in the nutrition consultation and any associated programs is voluntary. The client may choose to discontinue participation at any time and is not obligated to follow nutritional advice or programs.

Potential Risks:

Changes in diet and physical activity may involve risks, including but not limited to allergic reactions, digestive issues, or changes in medical condition. It is the client's responsibility to inform the nutritionist of any known medical conditions, allergies, or other health concerns that may affect their nutrition plan.

No Guarantees:

The nutritionist cannot guarantee specific outcomes or results from the nutrition plan or advice provided. Individual results may vary based on various factors, including adherence to the plan, individual metabolism, unexpected circumstances and overall lifestyle.

Release of Liability:

By signing this intake form, the client releases the nutritionist from any liability related to adverse outcomes or damages resulting from the implementation of the nutrition plan or advice provided. The client assumes full responsibility for their health and well-being.

Confidentiality:

All information provided in this intake form and during consultations will be kept confidential and will not be shared with third parties without the client’s explicit consent, except as required by law.

Acknowledgment and Agreement:

I have read and understood the above disclaimer. By signing below, I acknowledge that I have provided accurate and complete information to the best of my knowledge. I understand the risks associated with changes in diet and exercise and agree to release the nutritionist from any liability related to the nutrition services provided.
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Nutrition Client Intake Form

Personal Information

Health & Medical History

Dietary Habits

Lifestyle and Physical Activity

Goals and Expectations

Mental and Emotional Health

Additional Information