Dietitian Client Intake Form Template
Gather complete clinical, dietary, and lifestyle baselines before your initial consultation. Use the editable questionnaire below as a printable PDF form or copy it into your digital intake workflow.
Patient Intake Questionnaire
Clinical Nutrition Assessment & Health History
Section 1: Personal Information & Anthropometric Baselines
____________________________________________
____ / ____ / ________ | Age: _____ | [ ] M [ ] F
____________________________________________
Height: _____ cm / ft | Weight: _____ kg
_____ cm / inches
____________________ | [ ] Sedentary [ ] Active
Section 2: Medical Conditions & Health History
Please check any conditions you currently manage or have been diagnosed with:
Section 3: Medications & Daily Supplements
List all prescription drugs, over-the-counter medications, vitamins, and protein powders:
1. Medication: ____________________ | Dosage: ________ | Frequency: ________
2. Medication: ____________________ | Dosage: ________ | Frequency: ________
3. Supplements: ___________________________________________________________
Section 4: 24-Hour Dietary Recall & Eating Habits
| Time | Meal / Snack Description | Approx. Quantity / Portion |
|---|---|---|
| Morning Wake-up | e.g. Tea with sugar, biscuits | 1 cup, 2 biscuits |
| Breakfast | e.g. Poha or Paratha | 1 plate |
| Lunch | e.g. Roti, Dal, Sabji | 2 rotis, 1 bowl dal |
| Evening Snack | e.g. Chai + Namkeen | 1 cup, small bowl |
| Dinner | e.g. Khichdi / Rice + Curry | 1 medium bowl |
Section 5: Primary Health Goals & Consent
What are your top 3 objectives for nutrition counseling? (e.g. Sustainable fat loss, HbA1c reduction, improved energy, athletic recovery)
Consent Statement: I understand that nutrition counseling provides dietary guidance and education. It does not replace emergency medical diagnosis or care from my primary physician. I verify that all health history provided above is accurate.
Send digital intake forms automatically
Nutrena lets you send branded online intake links via WhatsApp or SMS. Client responses sync directly into their clinical profile with zero manual transcription.