Nutrition Client Intake Questionnaire
Please answer all questions to facilitate your initial visit.
Name
First Name
Last Name
E-mail
Phone Number
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Area Code
Phone Number
Today's Date
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Month
-
Day
Year
Date
What are your goals related to nutrition (i.e. why would you like to see a registered dietitian)? Please be as specific as possible.
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(e.g. eating less processed food, weight loss, gaining muscle, reduce gout pain, improve athletic/exercise performance, etc.)
Of the above goals listed, which is the highest priority?
For this highest priority goal, how important to you is it to achieve this goal, 1 being least important, 10 being the most important?
1
2
3
4
5
6
7
8
9
10
Least
Most
1 is Least, 10 is Most
What, if anything, have you tried before to accomplish this goal? What success, if any, did you make?
Do you currently follow any special kind of diet or have any dietary restrictions? If so, please describe.
(e.g. low salt, low carb, low fat, vegetarian, gluten-free, vegan, Kosher, etc.)
Do you have any food allergies? If so, please describe and include what symptoms you experience from the allergy.
(e.g. egg allergy with hives, seafood with tongue swelling)
Do you have any food intolerances? If so please describe and include what symptoms you experience from the intolerance.
(e.g. lactose intolerance with stomach pain and diarrhea)
Please list any health or medical issues you currently deal with.
(e.g. Type 2 Diabetes, high blood pressure, high cholesterol, Irritable Bowel Syndrome (IBS), constipation, bloating, nausea/vomiting, headaches, etc.
Have you seen a Registered Dietitian/Nutritionist before? If yes, what was your experience with them?
Current Height:
Current Weight:
Goal weight (if applicable):
What is your gender?
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What is your date of birth?
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Enter the message as it's shown
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By signing below, I attest that the above information provided is correct to the best of my knowledge.
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