Dietitian Patient Intake Form

Section 1 of 10 - 10% Complete

1 Personal Information

Full Name

Date of Birth

Gender

Phone Number

Email Address

Marital Status

Occupation

Emergency Contact

Address

2 Visit Details

Visit Type

Visit Date

Referring Doctor

Main Concern / Reason for Visit

Patient Goals

4 Family Medical History

Select any conditions that run in your family

Diabetes

Obesity

Heart Disease

Hypertension

Thyroid Problems

High Cholesterol

Cancer

5 Lifestyle Assessment

Sleep Patterns

Hours of Sleep per Night

Sleep Quality

Physical Activity

Type of Exercise

Frequency (days/week)

Duration (minutes/session)

Average Daily Steps

Sedentary lifestyle / Desk job

Stress & Mental Health

Stress Level

Emotional Eating

Stress Sources

Smoking & Alcohol

Do you smoke?

Alcohol Consumption

6 Eating Habits & Dietary Assessment

Daily Routine

Wake-up Time

First Meal Time

Number of Meals/Day

Water Intake (liters/day)

24-Hour Dietary Recall

Breakfast

Lunch

Dinner

Snacks

Beverages (Coffee, Tea, Juices, etc.)

Food Preferences & Habits

Foods You Like

Foods You Dislike

Eating Out Frequency

Cultural/Religious Diet

Previous Diet History

Previous Diets Tried

7 Body Measurements & Anthropometry

Basic Measurements

Weight (kg)

Height (cm)

Waist Circumference (cm)

Hip Circumference (cm)

Neck Circumference (cm)

Body Composition (If Available)

Body Fat %

Muscle Mass %

Water %

Visceral Fat Level

BMR (Basal Metabolic Rate)

8 Lab Tests & Blood Work

Enter recent lab test results if available

Vitamin D (ng/mL)

Vitamin B12 (pg/mL)

HbA1c (%)

Total Cholesterol (mg/dL)

LDL Cholesterol (mg/dL)

HDL Cholesterol (mg/dL)

Triglycerides (mg/dL)

TSH (Thyroid) (μIU/mL)

Hemoglobin (g/dL)

Ferritin (ng/mL)

Other Lab Results

9 Nutrition Diagnosis (Dietitian Notes)

PES Statement: Problem, Etiology, Signs/Symptoms

Primary Problem

Etiology (Causes)

Signs & Symptoms

Additional Dietitian Notes

10 Meal Plan & Recommendations

Recommended Daily Calories

Protein (grams/day)

Carbs (grams/day)

Fats (grams/day)

Meal Plan Type

Dietary Recommendations & Instructions

Next Follow-up Date

Follow-up Notes