Nutrition Counseling Intake Form

Nutrition Counseling Intake Form — Form Fields

This healthcare template includes 8 fields. Collect dietary history, health goals, and lifestyle information before a nutrition counseling session. Helps dietitians create personalized nutrition plans. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Primary Health Goal(s) (select all that apply) (checkboxes, required) — options: Weight loss, Weight gain / muscle building, Manage a health condition (diabetes, heart disease, etc.), Improve energy levels, General healthy eating
• How would you describe your current diet? (multiple choice, required) — options: Omnivore (eat everything), Vegetarian, Vegan, Gluten-free, Other
• Food Allergies or Intolerances (long text, optional)
• How many meals do you typically eat per day? (number, optional)
• How often do you cook meals at home? (multiple choice, optional) — options: Most meals, About half the time, Rarely
• Describe a Typical Day of Eating (long text, optional)
• Medical Conditions Affecting Diet (long text, optional)