Nutrition Assessment and Goals Form

Nutrition Assessment and Goals Form — Form Fields

This healthcare template includes 12 fields. Assess dietary habits and health goals for patients starting nutrition counseling or a wellness program. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Email Address (email, required)
• Date of Birth (text, required)
• Current Weight (lbs) (number, required)
• Height (inches) (number, required)
• Primary Nutrition Goal (dropdown selection, required) — options: Weight Loss, Muscle Gain, Manage Chronic Disease, Improve Energy, Improve Digestion, General Wellness, Sports Performance
• Dietary Restrictions or Preferences (checkboxes, optional) — options: Vegetarian, Vegan, Gluten-Free, Dairy-Free, Kosher, Halal, No Restrictions
• Describe Your Typical Daily Diet (long text, required)
• How Many Meals Do You Eat Per Day? (number, required)
• How Often Do You Exercise? (dropdown selection, required) — options: Never, 1-2 times/week, 3-4 times/week, 5+ times/week, Daily
• Do You Have Any Diagnosed Medical Conditions Related to Nutrition? (multiple choice, required) — options: Yes, No
• List Conditions if Applicable (long text, optional)