Dietary Assessment Form Template

Collects a person's complete eating history in an organized way, from allergies to activity level.

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Full Name

First Name

Last Name

Date of Birth

Gender

Male Female Other Prefer not to say

Email Address

Phone Number

Address

Street Address

City

State / Province

ZIP / Postal Code

Do you follow a specific diet?

Yes No

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?

List your favorite foods

List your least favorite foods

How active is your lifestyle?

Sedentary Lightly active Moderately active Very active

Do you have any specific dietary goals?

Do you have any medical conditions that affect your diet?

Are you currently taking any medications that affect your diet?

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