Confidential Intake Form
Nutrition Counseling

Name Date

Daytime Phone No. Evening Phone No

Email Address

Sex Male Female Age Height Weight

Goal Weight Occupation

Referred by

Reasons for visit General Nutrition/ Better Eating Habits Diet for Weight Loss Diet for Weight Gain Vegetarian Diet Sports Nutrition

Are you under a doctor's care? Yes No If so, for what?

Have you been diagnosed by a doctor for any nutrition -related problems (such as anemia, high cholesterol, hypoglycemia, gastrointestinal problem, thyroid disorder, etc) Yes No If so, please specify?

If you believe you have a nutrition related problem or metabolic disorder, you must see a doctor for an accurate diagnosis.

What, if anything, have you done previously to manage your nutrition-related concerns?

Current Medications

Vitamins, Minerals, & Herbal Supplements

Exercises
Do you exercise? Yes No If no, why?

Types How often? (times/week)

Duration

How long have you been on this exercise program?

Food Choice Inventory
Do you have ethnically specific food preferences (i.e. Chinese, Filipino, Mexican,etc?) Yes No If yes, please specify

Food dislikes

Food Allergies/ Intolerances

Meal Planning

Who plans your meals?

Who cooks?

Who shops? Is a list used? Yes No

How often do you eat out/week?

How often do you eat at a fast food restaurant?

Other people's homes Banquets or Meetings

Finer Dining Restaurants

Beverages

Do you drink alcohol? Yes No If so, what?

Weekly Amount

Do you drink coffee/ tea? Yes No If so Regular Decaf Daily Amount

What other beverages? Daily amount?

What do you feel are your "worst" food habits?