Updated 03/2020

This is a basic adult nutrition intake form. I currently use it to send to my clients immediately after they schedule to complete on their own time before they come in for their first appointment. This form is not fillable via computer, but rather must be printed and completed with a pen. Best for in-person appointments and adult clients.

What information is gathered on the form?

  • Client’s personal information (mailing address, DOB, physician contact info, food allergies)
  • Client’s medical history and medication list
  • Prompts to bring in recent lab results for review
  • Questions regarding past hospitalizations, exercise routine, past RD visits
  • Emergency contact info
  • Diet history: typical foods consumed and meal times, diets tried in the past, fruit/vegetables/whole grain/water intake

This form is 2 pages long and will download in .pdf format.

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