Dietitian Intake Form

Nutrition Consultation Intake Form
Patient Name

First NameLast Name
Patient DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Referring Physician
Scheduled Appointment Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Height (if known)
Weight (if known)
What are 1-3 goals for our meeting?
Food Allergies/Intolerances (please list)
Medications/Supplements (please list)
Does your family/child follow any special diet? (ex: vegetarian/vegan, gluten free, etc)
Please record a 3 day food an exercise log. While recording this information, please continue to eat and drink like normal. Note the following:
- Time the meal/snack started
- Place where eating occurred (home, friend's house, restaurant, table, couch, etc.)
- Food and liquids consumed
  - Be as specific as possible about items consumed (for example, "8oz of 2% milk" instead of "glass of milk")
  - Include items added to food (ketchup, ranch, mayo, etc)
  - Include brand names if known
- Estimate the amounts of items consumed (1 cup, 1 tablespoon, one slice - try to avoid vague terms such as "a bowl" or "a glass")
- Include any exercise performed (activity, time, intensity - walking on treadmill, 30 min, 3mph)

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Nutrition Consultation Intake Form