Dietary Assessment Form Template

Dietary Assessment Form Template
Please fill out the following form to help us assess your dietary habits and needs.
Personal Information
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Gender
MaleFemaleOther
Contact Information
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Dietary Habits
Do you follow a specific diet?
YesNo
If yes, please specify the diet
How many meals do you eat per day?
Do you have any food allergies or intolerances?
Do you have any dietary restrictions?
Food Preferences
List your favorite foods
List your least favorite foods
Lifestyle
How active is your lifestyle?
SedentaryLightly activeModerately activeVery active
Do you have any specific dietary goals?
Medical History
Do you have any medical conditions that affect your diet?
Are you currently taking any medications that affect your diet?
Should be Empty: