Nutritionist Client Intake Questionnaire
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Non-binary
Prefer not to say
Email
Phone
Health Information
Height
Weight
Current medical diagnoses or conditions
Current medications or supplements
Known allergies or food intolerances
Lifestyle & Dietary Habits
Briefly describe a typical day’s meals/snacks
Usual beverage consumption (water, coffee, juice, alcohol, etc.)
Physical activity (type/frequency/intensity)
What are your biggest nutrition challenges?
What are your nutrition or health goals?
Additional Notes
Anything else you would like to share?