Diet Consultation Form

Gather a person's health history, eating habits, and goals ahead of their first nutrition appointment.

Use this template

Full Name

First Name

Last Name

Age

Date of Birth

Phone Number

Email

Address

Street Address

City

State / Province

ZIP / Postal Code

Current Weight (kg)

Current Height (cm)

Desired Body Weight (kg)

Reasons you want to start a diet

What are your nutrition goals?

Do you have any preference in food diet?

Have you followed any diet trend?

Yes No

Was the diet trend you followed effective?

Very effective Somewhat effective Not effective Not applicable

Please share the diet trend you followed and how effective it was

Do you have any eating disorder?

Yes No Prefer not to say

If yes, please share more so we can take it into account

Do you have any allergies? If yes, please list them below

Are you currently taking any medications? If yes, please list them below

Are you smoking?

Yes No

Are you drinking alcohol?

Yes No

Are you a vegetarian?

Yes No

What caffeinated beverages are you drinking?

If you play sports, please list them below and how often

Do you go to the gym? How often do you exercise?

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