Meal Planning Program
Client Intake Form
I. Personal Information
First Name
Last Name
Date of Birth
Gender
Street Address
Street Address Line 2
City
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact Name
Emergency Contact Phone Number
II. Health and Lifestyle Information
Height
Current Weight
Target Weight
Occupation
Typical Daily Activity Level
Sedentary
Lightly Active
Moderately Active
Very Active
Extra Active
Other (please specify):
Do you have any known medical conditions?
If yes, please specify:
Do you have any food allergies or intolerances?
If yes, please specify:
Are you currently taking any medications or supplements?
If yes, please list:
Do you have any dietary restrictions (e.g., vegetarian, vegan, gluten-free, dairy-free)?
Do you have any specific dietary preferences?
Do you have any current or past eating disorders or disordered eating patterns?
How would you rate your current stress level (1-10, 1 being low, 10 being high)?
How many hours of sleep do you typically get per night?
Do you smoke or use tobacco products?
Do you consume alcohol?
If yes, how often?
III. Nutrition and Eating Habits
Describe a typical day of eating, including meals and snacks:
How often do you eat out?
How often do you cook at home?
What are your biggest challenges with meal planning and healthy eating?
What are your current nutritional goals?
Weight loss
Weight gain
Improved energy
Better digestion
Managing a medical condition
Other (please specify):
What are your current nutritional goals? (1-10, 1 being very little to no knowledge, 10 being very high level of knowledge)?
What are your current nutritional goals? (1-10, 1 being negative relationship, 10 being positive relationship)?
Are there any foods you particularly dislike?
IV. Program Options
Please select all that apply
Individual Meal Planning Programs:
Personalized Meal Plans (weekly/monthly)
One-on-One Nutrition Coaching
Grocery Shopping Assistance/Guidance
Cooking Demonstrations/Lessons
Pantry Cleanout/Organization
Specific Macro/Micro nutrient planning
Group Meal Planning Programs:
Group Nutrition Workshops
Group Cooking Classes
Group Meal Prep Sessions
Online Group Support/Accountability
Specialized Programs:
Sports Nutrition
Weight Management
Diabetic Meal Planning
Family Meal Planning
Senior Nutrition
Online/Remote Programs:
Online Consultations
Digital Meal Plan Delivery
Virtual Cooking Demonstrations
Program Suitability and Expectations
What are your expectations from this meal planning program?
What specific outcomes are you hoping to achieve?
How much time per week are you willing to dedicate to meal planning and preparation?
What is your preferred method of communication?
Phone
In-person
What is your budget for this program?
On a scale of 1-5, how committed are you to making lifestyle changes? (1 being not committed, 5 being very committed)
What factors might hinder your success in this program?
Which of the offered services do you feel most aligns with your current needs and lifestyle?
Are you open to trying new foods and recipes?
How comfortable are you with technology for online program components?
If you are selecting a group program, are you comfortable sharing your experiences and goals with others?
Do you have any concerns or questions about the program?
Agreement and Consent
I understand that the information provided in this form will be kept confidential and used for the purpose of developing a personalized meal planning program.
I understand that this program is not a substitute for medical advice and that I should consult with my doctor before making any significant dietary changes.
I consent to participate in the chosen meal planning program.
Signature
Client Intake Form Insights
Client Intake Form Insights
Please remove this client form insights section before publishing.
Let's break down this client intake form section by section, providing detailed insights into its purpose and importance:
Section 1: Personal Information
Purpose: This section establishes basic identification and contact information. It's crucial for:
- Record-keeping and administrative purposes.
- Communicating with the client.
- Having emergency contact details.
Insights:
- Date of Birth: Helps determine age-related nutritional needs.
- Emergency Contact: Vital for safety and in case of unforeseen circumstances.
- Address: Can be useful for understanding the client's environment (e.g., access to grocery stores, cultural influences).
Section 2: Health and Lifestyle Information
Purpose: This is the core of the form, gathering critical data about the client's health status and lifestyle habits. It's essential for:
- Identifying potential health risks and limitations.
- Tailoring the meal plan to individual needs.
- Understanding the client's daily routine and activity level.
Insights:
- Medical Conditions/Medications: Crucial for identifying potential food interactions and dietary restrictions.
- Food Allergies/Intolerances: Essential for preventing adverse reactions.
- Dietary Restrictions/Preferences: Allows for personalized meal planning that aligns with the client's beliefs and needs.
- Activity Level: Determines calorie and macronutrient requirements.
- Stress/Sleep: Impacts eating habits and overall health.
- Substance Use (Smoking/Alcohol): Can influence nutritional needs and health outcomes.
- Eating Disorders/Disordered Eating: These questions are extremely important. If a client answers yes, a referral to a specialist is very important.
Section 3: Nutrition and Eating Habits
Purpose: This section delves into the client's current dietary patterns, challenges, and goals. It helps to:
Assess their current nutritional intake.
Identify areas for improvement.
Understand their relationship with food.
Uncover any emotional eating patterns.
Insights:
Typical Day of Eating: Provides a snapshot of their current diet.
Eating Out/Cooking Habits: Indicates their level of food preparation skills and reliance on restaurant meals.
Challenges with Meal Planning: Reveals obstacles that need to be addressed.
Nutritional Goals: Defines the client's desired outcomes.
Relationship with Food: This is an important, and sometimes sensitive area. It helps to understand if there are any unhealthy patterns that need to be addressed.
Section 4: Program Options
Purpose: This section outlines the various services offered, allowing the client to select the programs that best suit their needs and preferences. It helps to:
Clearly communicate the available options.
Determine the client's desired level of support.
Streamline the program selection process.
Insights:
Offering a range of individual, group, and specialized programs caters to diverse client needs.
Including online/remote options expands accessibility.
Section 5: Program Suitability and Expectations
Purpose: This section assesses the client's readiness for the program and ensures alignment of expectations. It helps to:
- Determine their level of commitment.
- Identify potential barriers to success.
- Manage expectations and ensure client satisfaction.
Insights:
- Expectations and Goals: Clarifies the client's desired outcomes and helps to set realistic targets.
- Time Commitment: Ensures the client has sufficient time to dedicate to the program.
- Communication Preferences: Facilitates effective communication.
- Budget: Helps to determine affordability and program suitability.
- Commitment Level: Indicates the client's motivation and willingness to make changes.
- Concerns and Questions: Provides an opportunity for the client to address any uncertainties.
- Comfort with technology/groups: Ensures that the client is placed into a program that they are comfortable with.
Section 6: Agreement and Consent
Purpose: This section ensures that the client understands and agrees to the terms and conditions of the program. It provides:
- Legal protection for the practitioner.
- Clarity on confidentiality and disclaimers.
- Informed consent from the client.
Insights:
- The disclaimer regarding medical advice is crucial for protecting the practitioner.
- The confidentiality statement builds trust and encourages honest disclosure.
Follow-Up Questions (for the Practitioner)
Purpose: These questions guide the practitioner in analyzing the client's responses and making informed decisions about program suitability.
Insights:
- They promote critical thinking and ensure a thorough assessment of the client's needs.
- They help to create a plan of action.
Overall Importance:
This intake form is a valuable tool for:
- Gathering comprehensive client information.
- Developing personalized meal planning programs.
- Building strong client relationships.
- Ensuring client success.
- Mitigating legal risks.
By using this form and analyzing the client's responses thoughtfully, practitioners can provide effective and impactful meal planning services.
To configure an element, select it on the form.