Nutrition Consult Intake Form

Nutrition Consult Intake Form

Individual Consult with a Registered Dietitian Nutritionist / First Line Therapist
Full Name*

First NameMiddle InitialLast Name
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Primary Consult Reason
Do you have any medical diagnoses?
If so, please list them.
Do you have any mental health diagnoses?
Write "n/a" if you have not been diagnosed.
Are you currently working with a therapist/counselor/psychologist/psychiatrist?
If not currently, please write "n/a." If you are, please state the professional's name you are working with and what you are addressing in therapy/psychiatry.
Please list medications you are currently taking:
List all, including dosage and frequency.
Please list dietary or herbal supplements you are currently taking:
List all, include amount and frequency.
Height*
Feet, inches
Current weight*
Lbs
What obstacles do you face when trying to improve your diet?
Ex: Emotional eating, poor planning, etc.
Dietary preference:
Ex: No dietary restrictions, vegetarian, gluten-free, dairy-free.
Please reference the example below when answering the next question.

24-Hour Dietary Recall Example:

6am wake time

6:30am 8 oz black coffee with oatmilk creamer

8am 1 cup Life cereal + 8 oz milk, 1/2 banana, 2 Tbsp hemp seeds

12pm Veggie Chipotle burrito with sofritas

3pm Prime drink

6pm 3/4 cup rice, 1 cup Thai yellow curry with green beans and potatoes

8:30pm 1/2 cup raspberry sorbet

10:20pm bedtime
24-Hour Dietary Recall
Please be as specific as possible when listing all beverages and foods consumed on an average day, including snacks or candy. Please also list sleep and wake times.
Food Frequency Questionnaire

How many days per week do you eat or drink the following:
Processed sugar (cookies, ice cream, etc.)
Sugar sweetened beverages (soda, juice, etc.)
Diet drinks
Alcoholic beverages
Beans/Lentils
Nuts/Seeds
Berries
All other fruit
Refined grains (white rice, white pasta, white bread, chips, crackers)
Whole grains (brown rice, whole wheat bread, oats, quinoa, corn)
Cruciferous vegetables (broccoli, cauliflower, brussels sprouts)
Dark leaky green vegetables (spinach, kale, arugula)
Fast food
Eggs
Fish
Processed meat and cheese
Restaurants/takeout
Microwaveable/pre-made meals
Foods you love (and prefer not to live without):
Foods you dislike:
How many ounces of water do you drink per day:

Not sure, not enoughNot sure, I think I drink enoughOther
Do you have any food allergies?

YesNo
If yes, which one(s) and what kind of reaction? (i.e. Hives, itching, swelling):
Do you have any food sensitivities?

YesNo
If yes, which one(s) and what kind of reaction? (i.e. Bloating, diarrhea):
Lifestyle Questions

Please answer the following questions based on the last 2 weeks.
How many hours of sleep, on average, do you get each night?
Example: 6.5 hours
How would you describe your sleep quality? (Deep, restful, interrupted)
Please also include if you wake up to pee and at what time(s).
Do you exercise? If so, what type and how long?
Example: Yes, pickeball 1 hour/week and weight lifting 2x/week for 30 minutes. No, I don't exercise other than day-to-day activities around the house or to-and-from work.

How many days a week do you exercise intentionally?

	1	2	3	4	5	6	7

1 is Least, 7 is Most

Rate your stress on a scale of 1 to 10:

	1	2	3	4	5	6	7	8	9	10

1 is Stress-free, 10 is Extremely stressed

Where does stress originate (Work, school, family, etc.)?
Ex: Overworking, relationships, health issues, etc.
What helps you relax?
Ex: Epsom salt baths, nature, exercise, deep breathing, naps, etc.
Have you done genetic testing, nutrigenomics, food sensitivity or stool testing?

NoYes
If yes, which one(s):
If no, would you be open to testing?
Have you taken antibiotics in the last year?

NoYes
Are you currently on, or have you ever been on probiotics before?

In the pastCurrently takingNever
If so, please list which probiotic(s):
Please include which you have tried and any reactions or physiological responses to probiotics you've taken, if any. (E.g. Lactobacillus biffidum (or Brand) - increased BM frequency, larger stools, etc)
Gut Health Assessment

Please be specific and answer based on the past 2 weeks.
Bowel movement frequency:

Once a day2-3 times a day>3 times a dayOther
Stool consistency:

WateryLooseFormed like a bananaFormed with ridges and lumpsHard to passPellets
What is the color of your stool?

Pale, colorlessMustard yellowGreenLight brownDark brownBlack/tarry stoolsBloody stools
GI symptoms:

ConstipationDiarrheaMucous in stoolBloatingGasAbdominal painAcid refluxNauseaVomitingNone of the aboveOther
Client Needs

What would you like help with?
What would you like out of this visit with the dietitian?
Ex: Supplement recommendations, diet changes, lifestyle review, meal plan, etc.

On a scale of 1-10, how likely are you to make dietary changes?

	1	2	3	4	5	6	7	8	9	10

1 is Not likely, 10 is Very likely

Are you open to taking dietary supplements?

YesYes, preferably powders or chewableI prefer food but open to supplements, if recommended
Which service would you like?

Standard plan (Complete history, supplement/medication review, lifestyle/stress pattern analysis, dietary intake assessment, review of lab results, personalized diet and supplement recommendations.)Premium plan (Requires an extra $150 to include a detailed, personalized meal plan with a full week's worth of meals adapted to meet client-specific dietary preferences, calories, macronutrient and micronutrient targets with recipes and a grocery list.)
How many dietitian visits would you like?

Initial consultInitial consult + follow-up visits regularlyInitial consult + follow-up visits as-neededOther
Please share any other pertinent information you'd like the dietitian to know about your dietary needs and lifestyle (feel free to share your favorite cuisine or ice-cream flavor!):
Please upload your latest blood work results (Vitamin B12, Iron, Ferritin, insulin, Hemoglobin A1c, Vitamin D3, Zinc, homocysteine, C-RP, AM Cortisol, folate, blood lipids panel with cholesterol, HDL, LDL, triglycerides, etc), bone density scans, stool tests, genetic testing, body composition results, etc. Alternatively, please bring a copy of any pertinent paperwork to your first appointment.

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Thank you for filling out this questionnaire!
Liability Waiver

By signing below, you agree to the following:
Purpose: Nutritional counseling improves health and well-being but does not diagnose medical conditions.
Information: Clients must provide accurate personal and medical details, kept confidential under HIPAA.
Medical Issues: Suspected conditions will be referred to a physician.
Client Responsibility: Disclose medical conditions and consult doctors before altering treatments.
Recommendations: Clients are responsible for following dietary and supplement advice.
Liability: Clients assume risks and release the RDN from liability.
Telehealth: Services may use a HIPAA-compliant platform.
Payment: Fees are due before each session.
Termination: Either party can terminate with notice, but fees must be paid for services already provided.
By signing below, I agree that all information above is true*

Clear
I consent to treatment by Beautiful Minds Medical, Inc. for nutrition counseling as provided by the professional staff of Beautiful Minds Medical, Inc.
Should be Empty:

Nutrition Consult Intake Form

Food Frequency Questionnaire

Lifestyle Questions

Gut Health Assessment

Client Needs

Liability Waiver