By the Templateez Team · Licensed Attorney · June 2026

Nutrition & Dietetics Intake Forms: What Registered Dietitians Need to Capture at Client Intake

A registered dietitian who walks into a first session without knowing the client's A1C, current medications, or whether they have a history of disordered eating is working blind. Nutrition counseling is clinical work. It requires a clinical intake process. And yet most private-practice RDs cobble together a half-page form that collects a name, a phone number, and a vague "reason for visit" checkbox — then spend the first forty minutes of a sixty-minute session asking questions that should have been answered before the appointment started.

A thorough nutrition and dietetics intake form captures everything you need to build a safe, individualized nutrition care plan before the client sits down across from you. It protects you clinically, supports insurance reimbursement for medical nutrition therapy, and demonstrates to the client that you are a credentialed healthcare provider — not a wellness influencer with a meal plan template. Here is what that form should include.

Client demographics: the clinical foundation

Every nutrition assessment starts with the basics, but "basics" in dietetics means more than name and date of birth. Your demographic section needs to support clinical decision-making from the first line:

• Full name, date of birth, and contact information — standard across any healthcare intake. Include emergency contact, especially for clients with diabetes, eating disorders, or conditions that carry acute risk.
• Height, weight, and BMI — whether you calculate BMI in the office or ask the client to self-report, you need a baseline. BMI has well-documented limitations as a standalone metric, but it remains a required data point for insurance billing codes and for tracking trends over time. Note whether the value is measured or self-reported.
• Gender and sex assigned at birth — relevant for caloric needs calculations, hormonal considerations (PCOS, menopause), and eating disorder screening norms. Capture both if your client population warrants it.
• Occupation and work schedule — a nurse working 12-hour night shifts has fundamentally different meal timing needs than a remote software developer. Shift work is one of the strongest predictors of irregular eating patterns, and it should surface at intake, not three sessions in.
• Referring provider — who sent the client to you? A primary care physician, endocrinologist, gastroenterologist, bariatric surgeon, therapist, or self-referred? The referring provider shapes your treatment priorities and determines whether you need to coordinate care or send progress notes back.

Reason for visit: clinical, not casual

A "reason for visit" field that reads "lose weight" or "eat healthier" tells you almost nothing. Nutrition counseling spans a wide clinical spectrum, and your intake form should present specific categories so the client identifies their primary concern and you can prepare appropriately:

• Weight management — weight loss, weight gain, or weight maintenance. If weight loss, document the target and timeline expectations. Unrealistic goals (thirty pounds in two months) need to be addressed at the first session, and it helps to know that expectation before the client arrives.
• Chronic disease management — diabetes (Type 1 or Type 2, with most recent A1C), chronic kidney disease (CKD stage and most recent GFR, BUN, and creatinine), heart failure or cardiovascular disease (with lipid panel), celiac disease, inflammatory bowel disease (Crohn's or ulcerative colitis), and GERD. Each of these conditions has a specific medical nutrition therapy protocol, and missing the diagnosis at intake means missing the protocol.
• Sports nutrition and performance — training type, competition level, sport-specific demands. A marathon runner and a powerlifter have opposite fueling needs. Capture the training schedule, competition dates, and any history of relative energy deficiency in sport (RED-S).
• Eating disorder screening — this is the field most private-practice RDs leave off their intake form, and it is arguably the most important one. Include a validated screening tool — the SCOFF questionnaire (five yes/no questions, two or more positive responses warrant referral) or the EDE-Q (Eating Disorder Examination Questionnaire) for more detailed assessment. If a client screens positive, your nutrition counseling approach changes entirely. You are no longer prescribing a meal plan — you are coordinating with a therapist and potentially a psychiatrist, and calorie-focused interventions may be contraindicated.
• Food allergies and intolerances — true IgE-mediated allergies (peanuts, tree nuts, shellfish, dairy) versus intolerances (lactose, fructose, histamine). Document severity — does the client carry an EpiPen? Has there been anaphylaxis? The meal planning implications of a life-threatening peanut allergy are different from mild lactose intolerance.
• Pregnancy and lactation — current trimester, singleton or multiples, gestational diabetes status, pre-pregnancy weight, prenatal supplement regimen. Postpartum clients — breastfeeding exclusively, supplementing, or formula-feeding? Caloric and micronutrient needs vary significantly across these categories.
• Pediatric nutrition — growth curve percentiles, feeding difficulties, picky eating versus sensory-based food aversions, failure to thrive, food allergy management in children. Pediatric clients require parent or guardian involvement and different assessment tools.
• Tube feeding management — enteral nutrition type (nasogastric, gastrostomy, jejunostomy), formula brand and rate, tolerance issues, transition-to-oral goals if applicable. This is a specialized clinical population that many outpatient RDs encounter when clients are discharged from hospitals.

Medical history: the medications matter as much as the diagnoses

Nutrition does not exist in a clinical vacuum. Every medical condition and every medication the client takes affects what you recommend, what you avoid, and what lab values you monitor. Your intake form needs two equally detailed sections here — diagnoses and medications.

Diagnoses

• Diabetes — Type 1, Type 2, gestational, or prediabetes. Most recent A1C and fasting glucose. Current management approach (diet-controlled, oral medications, insulin, GLP-1 agonist). Hypoglycemia frequency.
• Chronic kidney disease — stage (1 through 5), most recent GFR, BUN, creatinine, and potassium. CKD stage determines protein, sodium, potassium, and phosphorus restrictions — getting the stage wrong means getting the diet wrong.
• Cardiovascular disease — heart failure class, coronary artery disease, hypertension. Most recent lipid panel (total cholesterol, LDL, HDL, triglycerides). Sodium restriction level if prescribed.
• GI disorders — celiac disease (confirmed by biopsy or serology?), Crohn's disease, ulcerative colitis, IBS (IBS-D, IBS-C, or IBS-M), GERD, gastroparesis, SIBO. Current GI medications and whether symptoms are in remission or active flare.
• Thyroid disorders — hypothyroidism or hyperthyroidism, current TSH, medication and dose. Thyroid function affects metabolic rate, weight, and energy, and clients frequently attribute weight changes to thyroid issues without knowing their current lab values.
• PCOS — polycystic ovary syndrome is one of the most common reasons women seek nutrition counseling. Document current medications (metformin, spironolactone, oral contraceptives), insulin resistance status, and fertility goals.
• Bariatric surgery history — procedure type (gastric bypass, sleeve gastrectomy, lap band, duodenal switch), date of surgery, current stage of post-surgical diet progression, and any complications (dumping syndrome, stricture, nutrient deficiencies). Post-bariatric nutrition requires lifelong monitoring of B12, iron, calcium, and protein status.

Medications and supplements

The medication list is not a formality — it drives your nutrition plan. Specific drug-nutrient interactions that your intake must surface:

• Metformin — depletes B12 over time. Monitor B12 levels and recommend supplementation.
• Insulin — type (rapid, long-acting, mixed), dose, and timing. Carbohydrate counting and meal timing are directly tied to the insulin regimen.
• GLP-1 receptor agonists (semaglutide, liraglutide, tirzepatide) — reduce appetite, slow gastric emptying, and can cause nausea that affects food tolerance. These medications are reshaping nutrition practice and clients on them need different counseling than clients managing weight through diet alone.
• Statins — may deplete CoQ10. Grapefruit interaction with certain statins (atorvastatin, simvastatin) needs to be flagged in dietary guidance.
• Warfarin — vitamin K intake must be consistent (not eliminated). Dramatic changes in green leafy vegetable consumption alter INR and can be dangerous. This is a critical drug-nutrient interaction that must be captured at intake.
• Corticosteroids — long-term use increases appetite, promotes weight gain, elevates blood glucose, and depletes calcium and vitamin D. Clients on chronic prednisone need a different nutritional approach than clients not on it.
• Current supplements — list all vitamins, minerals, protein powders, herbal supplements, and probiotics. Dosages matter. A client taking 10,000 IU of vitamin D daily without monitoring their 25-hydroxyvitamin D level is a different situation than one taking 1,000 IU.

Lab values

Request that clients bring their most recent lab work or authorize release from their physician. Key labs for nutrition assessment include CBC (anemia screening), CMP (glucose, electrolytes, kidney and liver function), iron panel with ferritin, vitamin B12, 25-hydroxyvitamin D, and prealbumin (a more sensitive marker of protein status than albumin, particularly useful in malnutrition screening). If the client has diabetes, A1C within the last three months. If they have CKD, a full renal panel.

Diet history: what the client is actually eating

This is the core of nutrition assessment, and it requires more than "tell me what you had for lunch." Your intake form should capture eating patterns with enough specificity that you can identify problems before the first counseling session begins:

• Current eating pattern — number of meals per day, number of snacks, general timing (breakfast at 7 AM, lunch skipped, large dinner at 8 PM). Irregular patterns, meal skipping, and late-night eating are data points, not just habits.
• Typical intake — a 24-hour recall (what the client ate yesterday, meal by meal) or a food frequency questionnaire (how often they eat specific food groups per week). The 24-hour recall is quick but may not be representative. The food frequency approach gives a broader picture but takes more time. Many RDs include a 24-hour recall on the intake form and send a three-day food diary for the client to complete before the first session.
• Cooking skills and frequency — does the client cook? How often? What is their skill level? A meal plan built around from-scratch cooking for a client who cannot boil pasta is going to fail. Knowing the client's kitchen competence shapes realistic recommendations.
• Grocery shopping — who does the shopping? How often? Where (supermarket, farmers market, online delivery, convenience store)? A client who shops once a month at Costco has different produce access than one who walks to a farmers market twice a week.
• Food budget — what the client spends on food per week or per month. Budget constraints are one of the most common barriers to dietary change, and recommending wild-caught salmon and organic berries to a client on a tight food budget is tone-deaf and clinically ineffective.
• Cultural and religious dietary practices — halal, kosher, vegetarian for religious reasons, fasting practices (Ramadan, Lent, intermittent fasting for religious or cultural reasons), traditional foods that are central to the client's diet. These are not restrictions to work around — they are frameworks to work within.
• Food preferences and aversions — foods the client loves, foods they refuse to eat, textures they cannot tolerate. This sounds trivial, but building a meal plan that includes foods the client dislikes guarantees non-adherence.
• Previous diets tried — keto, paleo, Whole30, Weight Watchers, Optavia, Noom, fasting protocols, very low calorie diets. Document what they tried, how long they followed it, what happened (weight lost and regained, felt terrible, saw results but could not sustain it). Diet history reveals patterns — a client who has done six restrictive diets in four years is a different clinical picture than a first-time nutrition client.
• Alcohol intake — type, frequency, quantity. Alcohol contributes significant calories, affects blood glucose, interacts with medications, and is a common barrier to weight management goals.
• Caffeine intake — coffee, tea, energy drinks, pre-workout supplements. Excessive caffeine can suppress appetite, disrupt sleep, and interact with certain medications.
• Water intake — estimated daily fluid consumption. Chronic underhydration is common and affects energy, digestion, and renal function.

Anthropometrics and body composition

Beyond the height and weight captured in demographics, your intake form should collect body composition data that supports clinical goal-setting:

• Weight history — highest adult weight, lowest adult weight, and the weight the client considers comfortable or their "usual." Weight history reveals patterns of cycling, dramatic fluctuations, and whether the current weight is an outlier or a trend. For clients with eating disorder histories, approach this section with clinical sensitivity — some may find detailed weight discussion triggering.
• Waist circumference — a better predictor of cardiovascular and metabolic risk than BMI alone. Men greater than 40 inches and women greater than 35 inches indicate elevated risk per current clinical guidelines.
• Body fat percentage — if available (bioelectrical impedance, DEXA, skinfold calipers). Note the method, since accuracy varies significantly between measurement tools.
• Weight goals — gain, lose, or maintain, with the client's target weight and desired timeline. This is where you document expectations so you can address unrealistic goals clinically rather than ignoring them and watching the client become frustrated when their timeline is not met.

Lifestyle factors: what happens outside the kitchen

Nutrition does not happen in isolation. What a client eats is shaped by how they live, and your intake form needs to capture the lifestyle factors that will determine whether your recommendations are sustainable:

• Physical activity — type (cardio, resistance training, yoga, recreational sports), frequency (days per week), duration (minutes per session), and intensity. Activity level directly affects caloric needs, macronutrient distribution, and meal timing recommendations.
• Sleep — average hours per night and sleep quality. Poor sleep is strongly associated with increased appetite, insulin resistance, and impaired food decision-making. A client sleeping five hours a night is fighting hormonal headwinds (elevated ghrelin, suppressed leptin) that no meal plan can fully overcome.
• Stress level — self-rated (low, moderate, high) and primary stressors. Chronic stress elevates cortisol, promotes visceral fat storage, and drives emotional and stress eating. Identifying stress at intake allows you to incorporate stress-management strategies into the nutrition plan rather than treating food choices as the only variable.
• Work schedule — standard hours, shift work, rotating shifts, frequent travel. Shift workers — nurses, first responders, factory workers, flight crews — are among the most nutritionally underserved populations. Their circadian disruption affects glucose metabolism, appetite regulation, and meal access in ways that standard nutrition advice does not address. If your client works nights, your meal plan needs to account for that from day one. The health coaching intake guide covers similar lifestyle assessment from a broader wellness perspective.
• Social eating patterns — does the client eat most meals alone or with family? Do they eat out frequently? Are social situations a trigger for overeating? A client whose primary social life revolves around restaurant dinners and happy hours faces different challenges than one who eats most meals at home.

Clinical nutrition assessment: nutrition-focused physical exam and malnutrition screening

For RDs working in clinical settings or with medically complex outpatient populations, the intake should include fields for nutrition-focused physical findings:

• Nutrition-focused physical exam (NFPE) — visual and hands-on assessment of muscle wasting (temporal wasting, interosseous muscle loss, clavicle prominence), subcutaneous fat loss, fluid status (edema in extremities, ascites), and micronutrient deficiency signs in skin (dry, flaky, poor wound healing), nails (spoon nails indicating iron deficiency, Beau's lines), and hair (thinning, brittle, alopecia). These findings are documented in the clinical record and support malnutrition diagnosis coding.
• Malnutrition screening — use a validated tool. The Malnutrition Universal Screening Tool (MUST) is standard in outpatient settings and scores BMI, unintentional weight loss, and acute disease effect. The Subjective Global Assessment (SGA) is more comprehensive and widely used in hospital and renal populations. A positive screen triggers a full nutrition assessment and may change billing codes and treatment intensity.
• Swallowing assessment — relevant for clients with neurological conditions, head and neck cancer, or post-stroke dysphagia. If the client has swallowing difficulties, document the current diet texture level (regular, soft, mechanical soft, pureed) and liquid consistency (thin, nectar-thick, honey-thick). Coordinate with speech-language pathology if a formal swallowing evaluation has not been completed.

Insurance and billing: medical nutrition therapy coverage

Nutrition counseling is a healthcare service, and your intake form should capture the information needed to bill for it correctly. MNT is a covered benefit under specific conditions, and missing the billing details at intake means chasing them later or leaving money on the table:

• Insurance information — carrier, plan number, group number, subscriber name if different from client. Standard fields, but essential for MNT billing.
• Medicare MNT coverage — Medicare covers medical nutrition therapy for diabetes (Type 1 and Type 2) and chronic kidney disease (non-dialysis and dialysis). The initial year allows three hours of MNT; subsequent years allow two hours. If your client is a Medicare beneficiary with one of these diagnoses, they have a covered benefit that many do not know about. Your intake form surfaces this.
• Diagnosis codes for MNT — capture the referring provider's ICD-10 codes. MNT reimbursement requires a qualifying diagnosis, and the code must come from the referring physician, not the RD (in most states). Common qualifying codes include E11 (Type 2 diabetes), E10 (Type 1 diabetes), N18 (chronic kidney disease), and E66 (obesity, covered by some commercial plans).
• Number of authorized visits — has the insurance company pre-authorized a specific number of visits? Does the plan require a referral from the PCP? Is there a copay or coinsurance for MNT visits? Capturing these at intake prevents the uncomfortable conversation at session three when the client discovers their plan only covers four visits per year.
• Self-pay rates — if the client is paying out of pocket, document your session rates, package pricing if offered, and cancellation policy. Many RDs offer superbill generation for out-of-network reimbursement — note whether the client wants this.

HIPAA consent and authorizations

Nutrition counseling is a HIPAA-covered service when provided by a healthcare provider who transmits health information electronically (which includes billing insurance). Your intake must include:

• Notice of Privacy Practices acknowledgment — confirmation that the client has received and reviewed your NPP, as required by the HIPAA Privacy Rule.
• Consent to treat — authorization for the RD to provide nutrition assessment and counseling services.
• Release of information — authorization to communicate with the referring physician, primary care provider, therapist (critical for eating disorder clients), and any other members of the care team. Without this release, you cannot send progress notes back to the referring provider or coordinate care with a mental health professional.
• Telehealth consent — if you offer virtual nutrition counseling (and most private-practice RDs now do), a separate telehealth consent addressing technology risks, emergency procedures for remote sessions, and state licensure limitations.

HIPAA compliance in nutrition practice follows the same framework as other healthcare disciplines. Our HIPAA-compliant intake forms guide covers the regulatory requirements in detail.

Building a practice that documents like a clinical provider

The nutrition profession has spent decades fighting for recognition as a clinical discipline. Registered dietitians hold graduate degrees, complete supervised practice hours, pass a national board exam, and maintain continuing education requirements. The intake process should reflect that rigor. A thorough intake form — one that captures lab values, screens for malnutrition and eating disorders, documents drug-nutrient interactions, and supports MNT billing — communicates to the client, to referring providers, and to insurance companies that nutrition counseling is healthcare, not lifestyle coaching.

The overlap between nutrition intake and adjacent wellness disciplines is real but the clinical depth is different. Weight loss and wellness programs capture lifestyle goals and motivation, while health coaches focus on behavior change readiness and habit tracking. Nutrition intake goes deeper — into lab values, medication interactions, validated screening tools, and medical nutrition therapy protocols. The form should reflect that distinction.

If you are building documentation across a healthcare practice, the Healthcare Bundle includes nutrition and dietetics alongside 20 other healthcare categories, each with discipline-specific intake fields.