Client Intake Form -
Virtual Nutrition Consultation

Image conveying the benefits of virtual nutrition consultations for personalized dietary advice.

I. Personal Information

First Name

Last Name


Date of Birth

Gender


Email Address

Phone Number



Address

Street Address

Street Address Line 2


City/Suburb

State/Province


Postal/Zip Code

Country



Preferred Method of Communication

Preferred Language


Emergency Contact Name

Emergency Contact Phone Number

II. Health History

Primary Care Physician's Name

Primary Care Physician's Contact Information

List any current medical conditions:

List any past medical conditions or surgeries:

List all current medications, including dosages (prescription, over-the-counter, and supplements):

Do you have any known food allergies or intolerances?

Do you experience any of the following? (Check all that apply)


Are you currently pregnant, breastfeeding, or planning to become pregnant?

Do you have any history of eating disorders or disordered eating?

III. Lifestyle and Habits

Describe your typical daily activity level:

Do you engage in regular exercise?

Do you smoke?

Do you consume alcohol?

If yes, how often and how much?

How many hours of sleep do you typically get per night?

Describe your stress levels:

IV. Dietary Habits

Describe a typical day of eating, including meals and snacks:

How often do you eat out or order takeout?

Do you have any dietary restrictions or preferences? (Check all that apply)

Please select your current dietary pattern from the list below, or describe your own:


Do you regularly consume:


  • Fruits and vegetables? (How often?)
  • Whole grains? (How often?)
  • Lean proteins? (How often?)
  • Processed foods? (How often?)
  • Sugary drinks? (How often?)

How much water do you drink per day?

Do you currently work with any other health professionals? (Therapist, nutritionist, etc.)

Past Medical History: (Please provide a brief overview of any significant past illnesses, surgeries, or hospitalizations).

Family Medical History: (Please list any significant health conditions that run in your family).

Current Primary Care Physician (PCP) Name and Contact Information.

Do you take any nutritional supplements?

Do you track your food intake or macronutrients?

What are your biggest challenges with your current eating habits?

V. Goals and Expectations

What are your primary nutrition goals?

What specific outcomes are you hoping to achieve through these consultations?

On a scale of 1-10, how committed are you to making lifestyle and dietary changes? (1 = Not at all, 10 = Extremely)

What are your expectations for these virtual consultations?

Are you comfortable with virtual consultations?

Do you have access to a reliable internet connection and a device with video capabilities?

Are you comfortable with receiving meal plans, grocery lists, and other resources digitally?

Are you aware that virtual consultations are not a replacement for in person medical care?

Are you aware that Registered Dietitians and Nutritionists give nutritional advice, and do not prescribe medication?

VI. Suitability Assessment

Are you currently experiencing any severe symptoms that require immediate medical attention?

If yes, please seek medical help before proceeding.

Do you have a current diagnosed eating disorder that requires intensive therapy?

If yes, please seek help from a specialist in eating disorders.

Do you have any mental health conditions that significantly impact your daily life?

If yes, please seek support from a mental health professional.

Do you understand that virtual consultations may not be suitable for all medical conditions, and that in person consultation with a medical professional may be needed?

Are you able to provide accurate information regarding your health and diet?

Are you able to follow the advice given by the Registered Dietitian or Nutritionist?

VII. Consent and Agreement

I confirm that all information provided is accurate and complete to the best of my knowledge.

I understand that the Registered Dietitian/Nutritionist will use this information to develop a personalized nutrition plan.

I understand that the Registered Dietitian/Nutritionist will not provide medical diagnoses or prescribe medications.

I consent to receive communication via email, phone, or video as indicated.

I have read and agree to the [Your Practice/Company Name] privacy policy and terms of service.

Signature

Client Intake Form Insights

Please remove this client intake form insights section before publishing.


Client Intake Form Insights:

Let's break down the client intake form and delve into the insights behind each section:

Overall Purpose:

The primary purpose of this intake form is to:

  • Gather Comprehensive Client Information: To build a holistic picture of the client's health, lifestyle, and dietary habits.
  • Assess Suitability for Virtual Consultations: To determine if the client's needs and circumstances align with the scope and limitations of virtual nutrition counseling.
  • Establish a Foundation for Personalized Care: To use the gathered information to create tailored nutrition plans and recommendations.
  • Ensure Informed Consent and Legal Compliance: To protect both the client and the practitioner by obtaining necessary consent and adhering to privacy regulations.

Section-by-Section Insights:

1. Personal Information:

  • Insight: This section establishes basic client identification and contact information. It also helps understand preferred communication methods, which is crucial for virtual consultations.
  • Importance: Accurate contact information is vital for scheduling appointments, sending resources, and providing timely support.

2. Health History:

  • Insight: This is a critical section for identifying potential health risks, medical conditions, and medication interactions that may affect nutrition recommendations.
  • Importance: Understanding the client's medical history allows the dietitian to provide safe and effective advice. It also helps determine if a referral to a physician or other healthcare professional is necessary.
  • Mental health and eating disorder questions: These questions are very important to determine if the client is suitable for virtual consulations, or needs higher levels of care.

3. Lifestyle and Habits:

  • Insight: This section explores the client's daily routines, activity levels, and stress management techniques, all of which significantly impact dietary choices and overall health.
  • Importance: Lifestyle factors provide context for dietary habits and help the dietitian understand the client's challenges and opportunities for change.
  • Sleep and Stress: These factors can heavily influence eating habits, and overall health.

4. Dietary Habits:

  • Insight: This section delves into the client's current eating patterns, preferences, and challenges, providing a detailed picture of their dietary intake.
  • Importance: This information is essential for identifying nutritional deficiencies, unhealthy eating habits, and potential areas for improvement.
  • Dietary Restrictions and Preferences: This section is vital for creating meal plans that are both nutritious and palatable for the client.
  • Food Frequency and 24-Hour Recall (Optional): These tools provide even more detailed insights into the client's dietary intake, which can be helpful for identifying specific nutrient deficiencies or excesses.

5. Goals and Expectations:

  • Insight: This section clarifies the client's motivations for seeking nutrition counseling and their desired outcomes. It also assesses their commitment to making lifestyle changes.
  • Importance: Understanding the client's goals and expectations helps the dietitian tailor their approach and provide effective support.
  • Commitment Level: Assessing the client's commitment level helps the dietitian gauge their readiness for change and adjust their strategies accordingly.
  • Virtual consultation awareness: It is very important that the client understands the limitations of virtual consultations.

6. Suitability Assessment:

  • Insight: This section directly addresses the suitability of virtual consultations by assessing potential red flags and ensuring the client understands the limitations of this format.
  • Importance: This section is crucial for protecting the client's safety and ensuring that they receive appropriate care. It also helps the dietitian avoid providing services that are beyond their scope of practice.
  • Red Flags: Severe symptoms, diagnosed eating disorders, and significant mental health conditions may necessitate in-person care or specialized treatment.
  • Client understanding: Ensuring that the client understands that virtual consultations are not a replacement for medical care protects the client and the dietitian.

7. Consent and Agreement:

  • Insight: This section obtains the client's informed consent for the collection and use of their personal information and their agreement to the terms of service.
  • Importance: This section is essential for legal compliance and ethical practice. It protects the client's privacy and ensures that they understand the terms of the counseling relationship.
  • Privacy Policy and Terms of Service: These documents provide important information about data protection and the client's rights and responsibilities.

Key Considerations:

  • Confidentiality: Emphasize the confidentiality of the information provided in the intake form.
  • Accessibility: Ensure the form is accessible to clients with disabilities.
  • Regular Review: Periodically review and update the form to reflect changes in best practices and legal requirements.

By carefully considering these insights, you can create a client intake form that is both comprehensive and effective, enabling you to provide high-quality virtual nutrition counseling.


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