Nutrition Counseling Intake

Nutrition Counseling Intake — Form Fields

This healthcare template includes 8 fields. Gathers dietary habits, health conditions, and nutritional goals for registered dietitian consultations. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Date of Birth (text, required)
• Reason for seeking nutrition counseling (checkboxes, required) — options: Weight management, Diabetes management, Heart health, Food allergies / intolerances, Eating disorder recovery, Sports performance, General healthy eating
• How many meals / snacks do you eat per day? (dropdown selection, required) — options: 1–2, 3, 4–5, 6+
• Do you follow any special diet? (multiple choice, required) — options: Vegetarian, Vegan, Gluten-free, No special diet, Other
• Describe a typical day of eating (long text, optional)
• List any food allergies or intolerances (long text, optional)
• Any relevant medical conditions or medications? (long text, optional)