Nutrition Initial Assessment Intake Form

Why an Initial Assessment Matters

The first step toward any successful nutrition plan is gathering a clear picture of a clients health, lifestyle, and goals. An Initial Assessment Intake Form serves as the foundation for a personalized approach, helping dietitians and nutritionists:

• Identify medical conditions, allergies, and medication interactions.
• Understand current eating patterns, preferences, and cultural influences.
• Set realistic, measurable objectives aligned with the clients lifestyle.
• Track progress over time by comparing baseline data with followup results.

All information collected is confidential and used solely for the purpose of creating a safe, effective nutrition plan.

Key Sections of the Form

1. Personal Information

Full Name Date of Birth Email Address Phone Number

2. Health History

Medical Conditions (check all that apply) Hypertension Diabetes (Type 1) Diabetes (Type 2) Thyroid Disorder Heart Disease Other (please specify below) If "Other", please describe Current Medications & Supplements Food Allergies or Intolerances

3. Lifestyle and Activity

Occupation (sedentary, active, mixed) Typical Weekly Exercise (type & duration) Average Hours of Sleep per Night

4. Dietary Patterns

Number of Meals & Snacks Daily Food Preferences / Restrictions (vegetarian, vegan, religious, etc.) Daily Water Intake (cups or liters)

5. Goals & Motivations

Primary Nutrition Goals (weight loss, muscle gain, disease management, etc.) What motivates you to improve your nutrition?

6. Additional Information

Stress Levels (low, moderate, high) and Main Sources Support System (family, friends, healthcare team) Submit Assessment

How the Information Is Used

Once submitted, the completed form is reviewed by a qualified nutrition professional. The data guide the creation of a customized plan that may include:

• Calorie and macronutrient targets.
• Meal timing and portion strategies.
• Recommendations for specific foods or supplements.
• Behaviorchange techniques and goalsetting milestones.

Clients are encouraged to revisit the intake form after 46 weeks to assess progress, adjust targets, and address any new concerns.

Best Practices for Completing the Form

1. Be honest and detailed. Accuracy leads to safer and more effective recommendations.
2. Use common measurements. When listing portions, state grams, cups, or household measures.
3. Include all medications. Even overthecounter drugs or herbal supplements can affect nutrition.
4. Note any recent changes. Weight fluctuations, new symptoms, or diet changes should be recorded.
5. Save a copy. Keep a personal record for future reference or to discuss with other health providers.