Nutrition Counseling Patient Intake Form

Personal Information

Full Name Date of Birth Age Phone Number Email Address

Emergency Contact

Name Phone Number Relationship

Medical Information

Primary Reason for Visit Medical Conditions (list any current or past) Medications & Supplements Allergies

Nutrition & Lifestyle

Height Weight Describe your typical daily eating pattern Food intolerances, dislikes, or dietary restrictions Physical Activity Level Sedentary Light Moderate Active Very Active Nutrition Goals Anything else you'd like your nutrition counselor to know?