Nutrition Intake Form

Name: _______________________________________________Date: _____________

Home Phone: ____________________
Cell Phone _________________________
Email: _________________________________________________________________
Mailing Address:________________________________________________________
Date of Birth: ______________ Weight: ______ Height ______
Cholesterol level: _____Blood Pressure: ______
Reason for visit: _________________________________________________________
Have you

lost or

gained any weight in the last year? How Much? ______

Have you had any major surgeries? Yes No. If yes please explain:
________________________________________________________________________
________________________________________________________________________
What are you allergic to? Please include foods:
________________________________________________________________________
Do you smoke?

Yes

No How much? _____________________________________

What is your personal health like? __________________________________________

_______________________________________________________________________
What is your energy level on a scale of 1-10? _________________________________
What medications are you on? Please include name, dosage, and frequency?
________________________________________________________________________
________________________________________________________________________
What supplements are you on? Please include name, dosage, and frequency?
________________________________________________________________________
_________________________________________________________________________________________________
What are your goals with nutrition?
________________________________________________________________________
________________________________________________________________________
What challenges do you believe stand in the way of your goals?
________________________________________________________________________
________________________________________________________________________
1

Brief Medical History

Do you or your family have a history of any of the following?
If family, please indicate relationship.
Heart disease: _________________ High cholesterol: __________________________
High blood pressure: ___________ Stroke: __________________________________
Edema: ______________________ Thyroid problems: ________________________
Ulcers: ______________________ Gallstones: _______________________________
Liver disease: _________________ Kidney disease: ___________________________
Anemia: _______________________Indigestion: ______________________________
Heartburn: ____________________ Osteoporosis: ____________________________
Arthritis: ______________________Cancer: _________________________________
Anxiety: _______________________Depression: ______________________________
Diabetes Type 1 or Type 2 : _______________________________________________

Food Questions
How would you rate your overall knowledge of nutrition?
1 being very poor and 5 being excellent 1
2
3
4

How would you rate your practice of good nutrition?

1 being very poor and 5 being excellent
1
2
3

About how many times a day do you eat? ____________________________________

How many are meals? ____________________________________________________
How many are snacks? ___________________________________________________
Do you eat within a half hour of waking?

Yes

No

Sometimes

Do you consistently eat Lunch?

Yes No
If yes what are you likely to eat? ___________________________________________
_______________________________________________________________________
Do you consistently eat Dinner? Yes No
If yes what are you likely to eat? ___________________________________________
_______________________________________________________________________
Do you eat late at night? Yes No
If yes what are you likely to eat? ___________________________________________
_______________________________________________________________________
What kind of kinds of foods do you normally have in your fridge?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2

Do you notice a change in your mood or energy level when you do not eat?
Yes No If yes what is the change?
_______________________________________________________________________
What foods do you avoid? _________________________________________________
_______________________________________________________________________
What foods are you not willing to give up? ___________________________________
_______________________________________________________________________
Have you had an eating disorder in the past? _________________________________
Are you on any particular diet? ____________________________________________
How often do you eat out? _________________________________________________
What restaurants do you go to normally and what foods do you generally order?
________________________________________________________________________
________________________________________________________________________
How many drinks containing alcohol do you have per day? ____Per week? _______
What do you typically drink? ______________________________________________
Do you drink juice, soft drinks or other sugary drinks? What type and how often?
________________________________________________________________________
If you drink caffeinated drinks including energy drinks, how many do you consume
and what type are they?
________________________________________________________________________
How many glasses or fluid ounces of water do you drink per day? _______________
Do you enjoy cooking?
Yes No
How many meals do you cook a week? ______________________________________
What types of food do you cook?
________________________________________________________________________
Does anyone else in the house cook? ________________________________________
If so, do you help plan the meals they cook? __________________________________
Do you know how much you spend on food? _________________________________
If so, what is your weekly budget for food? __________________________________
Where do you typically shop? _____________________________________________
How motivated are you to develop a healthy lifestyle? _________________________