Dietitian Intake Form

Patient Name*

First NameLast Name

Patient DOB*

Date

Referring Physician*

Scheduled Appointment Date

Date

Height (if known)

Weight (if known)

What are 1-3 goals for our meeting?

Food Allergies/Intolerances (please list)

Medications/Supplements (please list)

Does your family/child follow any special diet? (ex: vegetarian/vegan, gluten free, etc)

Please record a 3 day food an exercise log. While recording this information, please continue to eat and drink like normal. Note the following:

Time the meal/snack started
Place where eating occurred (home, friend's house, restaurant, table, couch, etc.)
Food and liquids consumed
- Be as specific as possible about items consumed (for example, "8oz of 2% milk" instead of "glass of milk")
- Include items added to food (ketchup, ranch, mayo, etc)
- Include brand names if known
Estimate the amounts of items consumed (1 cup, 1 tablespoon, one slice - try to avoid vague terms such as "a bowl" or "a glass")
Include any exercise performed (activity, time, intensity - walking on treadmill, 30 min, 3mph)

Type a question

Was this a typical day? Why/why not?*

Exercise complete? (activity, time, intensity)*

Type a question

Was this a typical day? Why/why not?*

Exercise complete? (activity, time, intensity)*

Type a question

Was this a typical day? Why/why not?*

Exercise complete? (activity, time, intensity)*

1. My child eats meals with other family members*

2. The television is on in the same room or visible when my child is eating*

3. Our family eats an evening meal at a regular time*

4. Meals in our home are often rushed*

5. We eat meals in the kitchen or dining room*

6. We eat meals in the car*

7. Everyone in the household eats something different at meals*

8. At meals, my child eats the same food as everyone else*

9. Someone in our home cooks meals*

10. We say grace or have a ritual at the start of meals*

Thank you! We look forward to your visit!

Nutrition Consultation Intake Form