Basic Information:

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Occupation

Health & Medical History

Do you have any current medical diagnoses? (e.g., diabetes, IBS, high cholesterol) Please list.

Are you currently taking any medications or supplements? Please list.

Have you ever worked with a dietitian or nutritionist before? If so, what was that experience like?

Do you have any allergies or food intolerances? Please describe.

Have you experienced any recent weight changes? Please explain.

Please upload any recent lab work such as BMP, lipid panel, A1C, LFTs, iron panel, or any relevant micronutrient levels.

How would you describe your current eating pattern?

How many meals and snacks do you typically eat per day?

Do you typically cook at home, eat out, or order in? Estimate the percentage of each:

Describe a typical day of eating for you (including times):

What are your top 3 nutrition or health goals?

What challenges or barriers have prevented you from reaching these goals in the past?

On a scale of 1–10, how confident are you in making dietary changes right now? (1 = not confident at all, 10 = fully confident) Score:

How do you define success in working with a dietitian?

Is there anything else you’d like me to know before we begin?

Include a 3-day food journal

I give my consent to share information with primary care provider.

Signature

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