Virtual Consultations with Nutritionists
Client Intake Form
I. Personal Information
First Name
Last Name
Date of Birth
Gender
Phone Number
Email Address
Preferred Method of Communication
Emergency Contact Name
Emergency Contact Phone Number
II. Health and Medical History
Do you have any diagnosed medical conditions?
If yes, please specify:
Are you currently taking any medications or supplements?
If yes, please list:
Do you have any food allergies or intolerances?
If yes, please specify:
Do you have a history of eating disorders?
If yes, please provide details:
Have you had any recent surgeries or hospitalizations?
If yes, please provide details:
Do you have any digestive issues (e.g., bloating, constipation, diarrhea)?
If yes, please specify:
Are you pregnant or breastfeeding?
Yes
No
Not applicable
Lifestyle and Dietary Habits
What is your primary goal for seeking nutrition counseling? (Check all that apply)
Weight loss
Weight gain
Improved energy levels
Better digestion
Managing a medical condition (e.g., diabetes, hypertension)
Sports performance
General health and wellness
Other (Please specify):
How would you describe your current diet? (Check all that apply)
Standard American Diet
Vegetarian
Vegan
Pescatarian
Mediterranean
Keto
Paleo
Low-carb
Low-fat
Other (Please specify):
How many meals do you typically eat per day?
1
2
3
4+
How often do you eat out or order takeout?
Daily
3-4 times/week
1-2 times/week
> 8 cups
Do you cook at home regularly?
How much water do you drink daily?
< 4 cups
4-8 cups
> 8 cups
Rarely
Do you consume alcohol?
If yes, how often?
Daily
Weekly
Occasionally
Do you smoke or use tobacco products?
Physical Activity
How often do you exercise?
Never
1-2 times/week
3-4 times/week
Daily
What type of exercise do you typically do? (Check all that apply)
Walking
Running
Weightlifting
Mediterranean
Ketogenic (Keto)
Paleo
Low-carb
Low-fat
Gluten-free
Dairy-free
Intermittent Fasting
Other (Please specify):
Diet Preferences and Restrictions
Are you following or interested in any specific diets? (Check all that apply)
Vegetarian
Vegan
Pescatarian
Yoga/Pilates
Swimming
Cycling
Team sports
Other (Please specify):
Are there any foods you dislike or avoid?
If yes, please specify:
Are there any cultural or religious dietary practices you follow?
If yes, please specify:
Suitability for Virtual Consultations
Do you have access to a reliable internet connection and a device for virtual consultations?
Are you comfortable with virtual consultations?
Do you have any concerns about virtual consultations?
If yes, please specify:
Would you prefer in-person consultations if available?
Additional Information
What are your biggest challenges with your current diet?
What would you like to achieve through nutrition counseling?
Is there anything else you would like us to know?
Consent and Agreement
I understand that the information provided in this form will be used to assess my suitability for virtual consultations and to create a personalized nutrition plan.
I consent to the use of my data for these purposes.
Client Signature:
Client Intake Form Insights
Client Intake Form Insights
Please remove this client intake form insights section before publishing.
1. Client Information
Purpose:
- To establish basic client details for communication and record-keeping.
- To ensure the dietitian can contact the client and, if necessary, an emergency contact.
Insights:
- Collecting the client’s full name, date of birth, and gender helps personalize the consultation and tailor recommendations based on age and gender-specific needs.
- Emergency contact information ensures safety, especially for clients with medical conditions.
- Preferred communication methods help streamline the consultation process and ensure the client is comfortable with the chosen format (e.g., video call, email).
2. Health and Medical History
Purpose:
- To identify any medical conditions, medications, allergies, or dietary restrictions that may impact nutritional recommendations.
- To assess the client’s overall health status and identify potential red flags (e.g., eating disorders, digestive issues).
Insights:
- Medical conditions (e.g., diabetes, hypertension) and medications can influence dietary plans. For example, a client on blood thinners may need to monitor vitamin K intake.
- Food allergies or intolerances (e.g., gluten, dairy) are critical to avoid adverse reactions.
- A history of eating disorders requires a sensitive approach, and the dietitian may collaborate with a mental health professional.
- Digestive issues (e.g., bloating, constipation) can guide recommendations for gut health, such as increasing fiber or probiotics.
- Pregnancy or breastfeeding status ensures the dietitian provides appropriate nutrient recommendations (e.g., folic acid, iron).
3. Lifestyle and Dietary Habits
Purpose:
- To understand the client’s current eating patterns, preferences, and challenges.
- To identify areas for improvement and set realistic goals.
Insights:
- The client’s primary goal (e.g., weight loss, improved energy) helps the dietitian focus on specific outcomes.
- Current diet type (e.g., vegan, keto) provides a baseline for recommendations. For example, a vegan client may need guidance on plant-based protein sources.
- Meal frequency and eating out habits reveal potential gaps in nutrition or over-reliance on processed foods.
- Water intake and alcohol consumption highlight hydration status and lifestyle factors that may need adjustment.
- Cooking habits (e.g., cooking at home vs. eating out) help determine how much control the client has over their food choices.
4. Physical Activity
Purpose:
- To assess the client’s activity level and how it impacts their nutritional needs.
Insights:
- Exercise frequency and type (e.g., weightlifting, yoga) influence calorie and macronutrient requirements. For example, an athlete may need more protein for muscle recovery.
- Sedentary clients may benefit from guidance on increasing physical activity alongside dietary changes.
5. Diet Preferences and Restrictions
Purpose:
- To identify the client’s dietary preferences, restrictions, and cultural or religious practices.
Insights:
- Specific diets (e.g., keto, gluten-free) help the dietitian tailor meal plans that align with the client’s preferences and health needs.
- Disliked or avoided foods ensure the dietitian avoids recommending foods the client won’t eat.
- Cultural or religious practices (e.g., halal, kosher) are respected and incorporated into the plan.
6. Suitability for Virtual Consultations
Purpose:
- To determine if the client is a good candidate for virtual consultations and address any concerns.
Insights:
- Access to reliable internet and a device is essential for virtual consultations.
- Comfort with virtual consultations ensures the client is engaged and willing to participate.
- Concerns about virtual consultations (e.g., privacy, technical issues) can be addressed proactively.
- Preference for in-person consultations helps the dietitian decide if virtual sessions are appropriate or if referrals are needed.
7. Additional Information
Purpose:
- To gather open-ended feedback and insights into the client’s challenges and goals.
Insights:
- Challenges with the current diet (e.g., emotional eating, lack of time) help the dietitian address barriers to success.
- Desired outcomes (e.g., better digestion, weight loss) guide the creation of a personalized plan.
- Additional information (e.g., family history, stress levels) provides context for the client’s overall well-being.
8. Consent and Agreement
Purpose:
- To obtain the client’s consent for data use and ensure they understand the purpose of the intake form.
Insights:
- This section ensures compliance with privacy regulations (e.g., HIPAA) and builds trust between the client and dietitian.
How This Form Benefits the Consultation Process
- Personalization: The form provides a comprehensive overview of the client’s health, lifestyle, and preferences, enabling the dietitian to create a tailored nutrition plan.
- Efficiency: By gathering detailed information upfront, the dietitian can focus on actionable recommendations during the consultation.
- Safety: Identifying medical conditions, allergies, and medications ensures the client’s safety and avoids potential contraindications.
- Goal Alignment: Understanding the client’s goals and challenges helps set realistic expectations and measurable outcomes.
- Client Engagement: The form encourages clients to reflect on their habits and goals, increasing their commitment to the process.
Potential Improvements
- Incorporate a Food Diary: Ask the client to log their food intake for 3-7 days before the consultation for more accurate insights.
- Mental Health Screening: Include questions about stress, sleep, and mental health, as these factors impact dietary habits.
- Family History: Add a section for family medical history (e.g., diabetes, heart disease) to assess genetic risks.
- Readiness for Change: Include a question about the client’s readiness to make dietary changes (e.g., using a scale from 1 to 10).
This detailed intake form ensures that the dietitian or nutritionist has all the necessary information to provide effective, personalized, and safe virtual consultations. It also helps build a strong client-practitioner relationship by demonstrating a thorough understanding of the client’s needs and goals.
To configure an element, select it on the form.