Nutrition Intake Form

Instructions for your first nutrition consultation

Thank you for taking the time to thoughtfully answer the questions in this new client questionnaire. You’ll have ample opportunity to address any concerns that require more detail during your appointment.

Required for your first visit:

1. The completed new client questionnaire, along with the 3-Day Diet Diary included in the questionnaire.

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Instructions for completing the 3-Day Diet Diary:

  • Record information as soon as possible after the food has been consumed. Please include all beverages, even water.
  • Do not change your eating behavior at this time unless your doctor advises you to. The purpose of this food record is to analyze your present eating habits.
  • Describe the food or beverage consumed. e.g., milk – what kind? (whole, 2%, or nonfat); toast – (whole wheat, white, buttered); chicken – (fried, baked, breaded), etc.
  • Record the amount of each food consumed using standard measurements as much as possible, such as 8 ounces, 1/2 cup, 1 teaspoon, etc.
  • Include any additional items (i.e. condiments). For example: tea with 1 teaspoon sugar, potato with 2 teaspoons butter, etc.

2. Please send me any labs, blood tests or other pertinent medical information you think may be helpful prior to your visit.

If you have any questions, please contact me.