Nutrition & Dietetics Intake Forms & Client Questionnaires

A client referred by their endocrinologist for medical nutrition therapy to manage Type 2 diabetes and a fitness enthusiast looking to optimize macros for a bodybuilding competition are both sitting in your office, but they need fundamentally different assessments. The diabetic client requires carbohydrate counting education, medication-nutrient interaction review, and A1c-informed meal planning. The bodybuilder needs periodized nutrition, competition prep protocols, and supplement safety evaluation. A generic health questionnaire that asks “Do you have any dietary restrictions?” tells you almost nothing useful for either case.

The Nutrition & Dietetics intake form captures the clinical and behavioral data that drives individualized care. It starts with a comprehensive dietary history — not just what the client eats, but how they eat. Meal frequency and timing, eating environment (at a desk, in the car, at a table with family), food preparation methods, who does the cooking, grocery shopping habits, and typical restaurant frequency. It documents food allergies with severity level (anaphylaxis vs. intolerance vs. preference) and distinguishes between IgE-mediated allergies, celiac disease, lactose intolerance, FODMAP sensitivity, and self-reported food sensitivities that may or may not have clinical validation.

Medical Conditions That Change Everything

Nutrition counseling without medical context is guesswork. The form includes a dedicated section for conditions that directly affect dietary recommendations: diabetes (Type 1, Type 2, gestational, prediabetes), celiac disease, inflammatory bowel disease (Crohn’s, ulcerative colitis), chronic kidney disease with GFR stage, heart failure requiring sodium restriction, liver disease, eating disorders (anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID), PCOS, thyroid disorders, and food protein-induced conditions. Each of these conditions changes your recommendations in specific ways — a renal diet restricts potassium and phosphorus, not just protein, and the restrictions shift depending on whether the client is on dialysis.

Current medications matter because they interact with nutrients in ways clients rarely anticipate. Metformin depletes B12. Statins interact with grapefruit. Warfarin requires consistent vitamin K intake. Lithium requires stable sodium. Corticosteroids affect calcium absorption and blood glucose. The form captures the full medication list, including over-the-counter supplements, herbal products, and protein powders — because the client taking a turmeric supplement alongside blood thinners may not think to mention it unless you ask directly.

Body Composition and Weight History

Current weight is one data point. Weight history tells the story. The form captures highest adult weight, lowest adult weight, number of intentional weight loss attempts, methods used (calorie counting, keto, intermittent fasting, commercial programs, bariatric surgery, GLP-1 medications), and the outcome of each. It documents current body composition goals — weight loss, weight gain, muscle building, weight maintenance, or no weight-related goal (the client may be focused purely on managing a medical condition or improving energy). For clients with eating disorder history, the form handles this sensitively by flagging the history for the provider without framing weight as the primary intervention target.

Lab Work and Clinical Markers

Registered dietitians increasingly use lab values to guide medical nutrition therapy, and many states now allow RDs to order labs independently. The form includes fields for recent lab work: fasting glucose, hemoglobin A1c, lipid panel (total cholesterol, LDL, HDL, triglycerides), comprehensive metabolic panel (BUN, creatinine, eGFR, electrolytes, liver enzymes), CBC, thyroid panel (TSH, free T4), vitamin D, B12, iron studies (ferritin, TIBC, serum iron), and prealbumin for malnutrition screening. Having these values on intake lets you build a nutrition care plan grounded in objective data rather than dietary recall alone, which studies consistently show underestimates caloric intake by 20 to 40 percent.

Intake vs. Client Questionnaire

The intake form is your internal clinical document. You or your nutrition assistant complete it during the initial assessment, recording anthropometric measurements, clinical observations, and the nutrition diagnosis using IDNT (International Dietetics and Nutrition Terminology). It includes fields for MNT billing codes, referral source, and coordination with the client’s primary care provider or specialist. The companion client questionnaire is what you send to the client before their first appointment. It asks about food preferences, cooking skills, cultural food practices, budget constraints, and goals in language that feels accessible rather than clinical. It includes HIPAA authorization and signature blocks for consent to nutritional assessment and medical records release.

Pricing

Each form is $19.99 for the complete set (intake + questionnaire), $14.99 for intake only, or $9.99 for questionnaire only. All PDFs are fillable in Adobe Reader, password-protected against editing, and HIPAA-compliant.

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