Nutrition Consultation Client Intake Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Address
Occupation
Health Information
Height (cm)
Weight (kg)
What are your primary nutrition goals?
Do you have any medical conditions, allergies, or dietary restrictions?
Are you currently taking any medications or supplements?
Lifestyle & Eating Habits
Describe your typical physical activity (type, frequency):
Describe your typical daily meals and snacks:
List beverages you regularly consume (water, coffee, soda, etc.):
What challenges have you faced regarding nutrition?
Additional Information
Anything else you'd like your nutritionist to know?