Nutrition Counseling Intake Form - Alternative

Nutrition Counseling Intake Form - Alternative — Form Fields

This healthcare template includes 7 fields. Collect dietary habits, health goals, and medical history for new nutrition counseling patients. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Primary Nutrition Goal (dropdown selection, required) — options: Weight loss, Weight gain or muscle building, Managing a health condition (diabetes, heart disease, etc.), Improving energy and overall health, Sports performance, Eating disorder recovery
• Do you follow any of the following dietary patterns? (select all that apply) (checkboxes, optional) — options: Vegetarian, Vegan, Gluten-free, Dairy-free, Halal or Kosher, None
• List any known food allergies or intolerances (long text, optional)
• Do you take any dietary supplements? (multiple choice, required) — options: Yes, No
• How many meals do you typically eat per day? (dropdown selection, required) — options: 1–2 meals, 3 meals, 4–5 meals or more, Irregular / no set pattern
• Additional health information or context for your dietitian (long text, optional)