Nutritionist New Client Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Phone Number
Email Address
Address
City
State/Province
Postal/ ZIP Code
Emergency Contact Name
Emergency Contact Phone
Health Information
Height (cm/in)
Weight (kg/lb)
Do you have any medical conditions?
Medications or supplements
Allergies (food, medication, other)
Physical Activity Level
Sedentary
Lightly Active
Moderately Active
Very Active
What are your primary health/nutrition goals?
Challenges or barriers
Dietary Habits
How many meals per day do you usually eat?
Do you have any dietary restrictions?
Preferred cuisines or foods
Foods you dislike or avoid
Usual beverages (e.g., water, tea, coffee, soda)
Anything else you'd like your nutritionist to know?