Nutrition Counseling Client Intake Form
I. Client Information
First Name
Last Name
Date of Birth
Gender
Street Address
City/Suburb
State/Province
Postal/Zip Code
Phone Number
Email Address
Emergency Contact
First Name
Last Name
Phone Number
II. Health History
Primary Care Physician:
Physician's Phone:
List any current medical conditions: (e.g., diabetes, hypertension, hypothyroidism, etc.)
List any past medical conditions:
List any current medications, including dosages and frequency: (Prescription, over-the-counter, and supplements)
List any allergies or intolerances: (Food, medication, environmental)
Have you had any recent surgeries or hospitalizations? (Please specify)
Do you experience any of the following? (Check all that apply)
Frequent headaches
Digestive issues (e.g., bloating, constipation, diarrhea)
Fatigue
Sleep disturbances
Mood changes
Skin problems
Other:
Have you seen a registered dietitian or nutritionist before?
Do you have any family history of chronic diseases? (e.g., heart disease, diabetes, cancer)
III. Lifestyle and Dietary Habits
What are your current dietary habits? (Please describe a typical day of eating)
Do you follow any specific dietary patterns? (e.g., vegetarian, vegan, gluten-free, keto, etc.)
How often do you eat out?
How often do you consume processed foods?
How much water do you drink per day?
How often do you consume sugary drinks?
Do you consume alcohol?
Do you smoke?
What is your level of physical activity?
sedentary
lightly active
moderately active
very active
Other:
How many hours of sleep do you get per night?
What are your stress levels like?
low
moderate
high
Do you have any food preferences or dislikes?
Do you have any cultural or religious dietary restrictions?
Do you have any challenges with food preparation or access?
Do you have any concerns about your body weight or composition?
IV. Goals and Expectations
What are your primary goals for nutrition counseling? (e.g., weight loss, weight gain, improved energy, managing a medical condition, etc.)
What are your specific, measurable, achievable, relevant, and time-bound (SMART) goals?
What are your expectations from this nutrition counseling program?
On a scale of 1-10, how motivated are you to make dietary changes? (1 = not motivated, 10 = extremely motivated)
What obstacles do you anticipate that may hinder your progress?
What support systems do you have in place?
V. Service Suitability and Selection
Please select the services you are interested in: (Check all that apply)
Service | Why are you interested in this service? | Do you have any specific questions or concerns about this service? | Do you believe this service aligns with your goals and lifestyle? | |
|---|---|---|---|---|
Individualized Nutrition Counseling | ||||
Weight Management Program | ||||
Meal Planning Services | ||||
Grocery Store Tours | ||||
Cooking Demonstrations | ||||
Sports Nutrition Counseling | ||||
Medical Nutrition Therapy (for specific conditions) | ||||
Group Nutrition Classes | ||||
Online/Virtual Consultations |
Are you willing to keep a food journal?
Are you comfortable with regular follow-up appointments?
Are you comfortable with receiving educational materials and resources?
Are you ready to commit to making sustainable lifestyle changes?
VI. Consent and Agreement
I understand that the information I provide will be kept confidential and used for the purpose of providing nutrition counseling services.
I agree to provide accurate and complete information to the best of my ability.
I understand that nutrition counseling is not a substitute for medical advice and that I should consult with my PCP for any medical concerns.
I consent to receive communication from [Your Organization] via phone, email, or other means.
I have read and understand the terms and conditions of the nutrition counseling program.
Signature
Form Template Insight
Form Template Insight
Please remove this form template insight section before publishing.
Let's break down the client intake form and delve into its insights:
Overall Purpose and Design:
- Comprehensive Data Gathering: The form is designed to gather a wide range of information, covering personal details, medical history, lifestyle, dietary habits, and goals. This comprehensive approach ensures a holistic understanding of the client.
- Service Suitability Assessment: A key aspect is the focus on assessing the client's suitability for various nutrition counseling services. This is crucial for providing personalized and effective care.
- Client-Centered Approach: The form encourages clients to express their goals, expectations, and concerns, fostering a client-centered approach.
- Legal and Ethical Considerations: The consent and agreement section addresses legal and ethical considerations, ensuring transparency and protecting both the client and the practitioner.
Insights from Each Section:
Section 1: Personal Information:
- This section establishes basic client identification and contact information.
- "How did you hear about us?" provides valuable marketing data.
Section 2: Health History:
- This is critical for identifying potential health risks and contraindications.
- Information about medications and allergies is essential for safe and effective nutrition counseling.
- Family history can reveal genetic predispositions to certain diseases.
- This section can highlight if the client would be better served by a Medical Nutrition Therapy program.
Section 3: Lifestyle and Dietary Habits:
- This section provides insights into the client's current eating patterns, lifestyle choices, and potential areas for improvement.
- It helps identify dietary deficiencies, unhealthy habits, and potential barriers to change.
- Stress levels and sleep patterns are very important to overall health, and can greatly impact eating habits.
Section 4: Goals and Expectations:
- This section helps define the client's desired outcomes and motivation levels.
- SMART goals provide a framework for tracking progress and ensuring accountability.
- This section highlights the clients level of readiness for change.
Section 5: Service Suitability and Selection:
- This section allows the practitioner to tailor services to the client's individual needs and preferences.
- It ensures that the client understands the different services available and their potential benefits.
- This section helps to identify if the client has realistic expectations for the services provided.
Section 6: Consent and Agreement:
- This section protects the practitioner from liability and ensures that the client understands the terms of the program.
- It establishes a clear understanding of confidentiality and communication protocols.
Key Insights for the Practitioner:
- Identifying Red Flags: The form helps identify potential red flags, such as serious medical conditions, eating disorders, or unrealistic expectations.
- Personalized Care: The information gathered allows the practitioner to develop a personalized nutrition plan that addresses the client's specific needs and goals.
- Building Rapport: The form provides a foundation for building rapport with the client by demonstrating genuine interest in their well-being.
- Effective Communication: The form helps to establish clear communication channels and expectations.
- Tracking Progress: The baseline information gathered can be used to track the client's progress over time.
- Marketing Information: Information on how the client heard about the service, can be used to better target marketing.
In essence, this intake form acts as a foundational tool for effective nutrition counseling. It allows the practitioner to:
- Understand the client's unique circumstances.
- Develop a tailored plan.
- Establish a strong client-practitioner relationship.
- Ensure ethical and legal compliance.
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