Nutrition Consultation template

A nutrition consultation intake form that asks the two questions most food questionnaires skip: what a typical day of eating actually looks like, and how much cooking the person realistically does in a week. Goals, dietary pattern, and energy levels round it out, and a branch collects the managing clinician's name when a diagnosed condition is involved.

Use this template Start free — no card

11 questions · works on the free plan (500 responses/month) · fully customizable

1 built-in logic rule

What’s inside

The questions this template ships with — rename, reorder, or delete any of them in the builder.

01Your contact detailsContact info

02What brings you to a nutrition consultation?Dropdown

03Are you working with a doctor on a diagnosed condition?Multiple choice

04Which condition, and who is managing it?Short text

05Do any of these describe how you eat?Checkboxes

06Walk us through a typical day of eatingLong text

07How would you rate your energy through the day?Rating scale

08How much cooking do you realistically do in a week?Multiple choice

09What would a good outcome look like in three months?Long text

When to use this template

A dietitian in private practice replacing a three-page food diary attachment that clients returned half-filled
A sports nutritionist collecting training context and eating patterns before a performance consult
A clinic taking referrals for diabetes or cholesterol management, where knowing which clinician is managing the condition matters from day one
A wellness program running group consultations that need a consistent starting picture for everyone

Tips to get more from it

The typical-day question is the only required free-text field, and its description asks for an honest average rather than a good day. That phrasing is what makes the answers usable
The cooking-frequency question exists so the plan matches the person's life — a scratch-cooking plan handed to someone who rarely cooks is a plan that gets abandoned in week two
The diagnosed-condition branch collects the managing clinician's name and states plainly that you work alongside them, not in place of them. Keep that wording
Zunoform offers no HIPAA Business Associate Agreement, so use this for consultation scheduling and intake rather than as a clinical record

Questions people ask

What should a nutrition intake form ask?

Goals, dietary restrictions and allergies, a typical day of eating, energy levels, cooking capacity, and any diagnosed condition under a clinician's care. This template covers all six in eleven fields.

Why does the form ask how much I cook?

Because it changes the recommendation. A plan built on scratch cooking is not the same plan for someone eating mostly prepared food, and the consultation is more productive when the dietitian knows before the session starts.

Does this template work for a clinic handling medical nutrition therapy?

It handles the intake conversation well, but Zunoform does not sign HIPAA Business Associate Agreements, so protected health information under HIPAA belongs in a system whose vendor will. Use this for the pre-consultation picture and keep clinical notes elsewhere.