Nutrition Consult Intake Form

Nutrition Consult Intake Form

A visit with a dietitian nutritionist includes a nutrition assessment with personalized recommendations.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
DOB
Height *
Current weight *
Please list any dietary supplements or nutrition-related medications:*
Primary*

Weight LossGut HealthDetoxHealthy EatingNutrition for Brain HealthOther
Have you ever worked with a nutritionist before? If so, please list what worked and what didn't and why. *
Food Frequency Questionnaire

How many days per week do you eat or drink the following:
Processed sugar (cookies, ice cream, etc.)
Soda or juice
Diet soda or juice
Alcoholic beverages
Beans/Lentils
Nuts/Seeds
Berries
All other fruit
Refined grains (pasta, bread, chips, crackers)
Whole grains (brown rice, whole wheat bread, oats, quinoa, corn)
Cruciferous vegetables (broccoli, cauliflower, brussels sprouts)
Dark leaky greens (spinach, kale, arugula)
Fast food
Eggs
Fish
Red meat
Processed Meat (salami/cold cuts/deli)
Lean meats (chicken, turkey, fish)
Dairy products (milk or yogurt)
Cheese
Plant-based alternatives (soy milk, tofu, cheese, yogurt)
Fermented foods (kimchi, sauerkraut, kombucha)
Restaurants/takeout
Microwaveable/pre-made meals
Lifestyle Questions

Please answer the following questions based on the last 2 weeks.
Have you done any of the following: genetic testing, nutrigenomics, food sensitivity, stool analysis?

NoYesOther
If yes, which one(s):
Have you taken antibiotics in the last year?

NoYes
Client Needs

What would you like help with?
What would you like out of this visit with the dietitian?*
Ex: Supplement recommendations, diet changes, lifestyle review, meal plan, etc.
Are you open to taking dietary supplements?

Yes, I'd like supplementsYes, preferably powders or chewablesI prefer food but open to supplements, if recommended
How many dietitian visits would you like?

Initial consultInitial consult + follow-up visits regularlyInitial consult + follow-up visits as-neededOther
Please share any other relevant information you'd like the dietitian to know.
Optionally, please upload any health-related labs or bring a copy to your first appointment.

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Thank you for filling out this questionnaire!
Liability Waiver

By signing below, you agree to the following:
Purpose: Nutritional counseling improves health and well-being but does not diagnose medical conditions.
Information: Clients must provide accurate personal and medical details, kept confidential under HIPAA.
Medical Issues: Suspected conditions will be referred to a physician.
Client Responsibility: Disclose medical conditions and consult doctors before altering treatments.
Recommendations: Clients are responsible for following dietary and supplement advice.
Liability: Clients assume risks and release the RDN from liability.
Telehealth: Services may use a HIPAA-compliant platform and client assumes risk.
Payment: Fees are due before each session.
Termination: Either party can terminate with notice, but fees must be paid for services already provided.
By signing below, I agree that all information above is true*

Clear
I consent to treatment by Beautiful Minds Medical, Inc. for nutrition counseling as provided by the professional staff of Beautiful Minds Medical, Inc.
Should be Empty:

Nutrition Consult Intake Form

Food Frequency Questionnaire

Lifestyle Questions

Client Needs

Liability Waiver