Meal Planning Program
Client Intake Form

Image of a structured meal plan with balanced food choices.

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

Do you have any known medical conditions?

Do you have any food allergies or intolerances?

Are you currently taking any medications or supplements?

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?

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?

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:

Group Meal Planning Programs:

Specialized Programs:

Online/Remote Programs:

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?

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

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.


Let’s be real—this form is fine, but ‘fine’ won’t win any awards. Wanna edit it into an Oscar-worthy performance? 🏆✨ Edit this Meal Planning Program Client Intake Form
This template not quite twisting and turning the way you need? Why not build your own perfect form with Zapof? It's got conditional logic and question branching to make things super dynamic – it's gonna be great!

More smart picks just waiting to be discovered!

Ready for a template joyride? 🎢 These collections are your ticket!

This form is protected by Google reCAPTCHA. Privacy - Terms.
 
Built using Zapof