Nutrition Consulation Form PDF Details

The Nutrition Consultation Form serves as a critical tool in bridging the gap between individuals seeking to improve their health and the professionals equipped to guide them towards these goals. This comprehensive document meticulously gathers personal information, including basic identifiers and physical dimensions, to tailor dietary and fitness recommendations to the unique needs of each client. A key section devoted to nutrition and fitness goals not only highlights the aspirations of the individual but also chronicles previous attempts at health optimization, providing a clear picture of what strategies have or haven't worked in the past. Medical history, medication usage, and specific dietary preferences or restrictions are thoroughly documented, ensuring any recommendations are safe and considerate of the individual's overall health landscape. Additionally, lifestyle habits, such as alcohol and tobacco use, exercise routines, and stress levels, are explored, offering a holistic view of factors that may influence nutritional needs and fitness capabilities. By encapsulating this wide array of personal health and lifestyle information, the Nutrition Consultation Form lays the groundwork for developing personalized, effective, and sustainable nutrition and fitness plans, underscored by the expertise of clinical dietician Jennifer Murphy MS, RD, LDN.

QuestionAnswer
Form NameNutrition Consulation Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesnutrition form blank, nutrition client intake form, nutrition consultation form pdf, nutrition form pdf

Form Preview Example

Nutrition Consultation Form

CLIENT INFORMATION:

Name: _________________________________________________ Date: _______________

Date of Birth: ____________________ Height: ____ (feet) ____ (inches)

Current Body Weight: ______

Desired Body Weight: _______

Lowest Body Weight: _______

Highest Body Weight: _______

Major: _________________________________________ Year at Bentley: _______________

Extra-Curricular Activities / Sports: ________________________________________________

_____________________________________________________________________________

Physician: _____________________________________ Phone: ________________________

NUTRITION AND FITNESS GOALS:

What are your nutrition and fitness goals?

1.________________________________________________________________________

2.________________________________________________________________________

3.________________________________________________________________________

4.________________________________________________________________________

5.________________________________________________________________________

What have you tried in the past to achieve your nutrition and fitness goals? This includes any diet or exer ise progra , supple e t use, ooks, et …

1.________________________________________________________________________

2.________________________________________________________________________

3.________________________________________________________________________

4.________________________________________________________________________

5.________________________________________________________________________

Jennifer Murphy MS, RD, LDN

Clinical Dietician

Nutrition Consultation Form

MEDICAL HISTORY AND MEDICATIONS:

Please list any relevant past medical history and current medications:

I.e. food allergies/intolerances, high cholesterol, diabetes, heart disease, ADHD, hypo/hyperthyroidism, recent surgeries, bowl disease, depression, eating disorders, recent

athletic i juries, a e ia, etc…

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Have you ever been diagnosed with an eating disorder?

Yes or

No

At what age did you get your first period?

_________

 

 

Do you get regular periods?

Yes or

No

 

 

When was your last menstrual period? ______________ How long did it last? ____________

Do you take any Vitamin / Mineral supplements? Yes or No If yes, please list below:

_____________________________________________________________________________

_____________________________________________________________________________

Are there any foods that you avoid? Yes or No If yes, please list below:

_____________________________________________________________________________

_____________________________________________________________________________

Are you a Vegetarian?

Yes

or

No

If yes, please circle which foods you DO NOT eat:

chicken

 

 

fish

 

 

dairy

 

 

eggs

 

red meat

On average, how many days a week do you consume alcoholic beverages?

 

0

1

2

3

4

5

6

7

 

 

 

 

 

On average, how many alcoholic drinks do you consume at one time?

 

 

0

1

2

3

4

5

6

7

8

9

10

11

12+

What types of alcohol do you consume?

 

 

 

 

 

 

Beer

 

 

 

 

Wine

 

 

 

Liquor

 

 

Other

Jennifer Murphy MS, RD, LDN

Clinical Dietician

Nutrition Consultation Form

On average, how many caffeinated beverages do you consume per day?

 

0

1

2

3

4

5

6

7

8

9

10

11

12+

What types of caffeinated beverages do you consume? I.e. energy drinks, coffee, tea, soda, etc.

_____________________________________________________________________________

_____________________________________________________________________________

Do you smoke (tobacco products)?

Yes

or

No

If yes, how many cigarettes per day?

0

1

2

3

4

5

6

7

8

9

10

11

12+

On average, about how many hours do you sleep: Weeknights ________ Weekends _______

Are you stressed?

Yes or

No

If yes, how stressed are you? Please circle

1

2

3

4

5

Not at all

A little

Moderate

Very

Extremely

How do you manage your stress?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Have you seen a counselor / therapist in the past, or are you working with someone presently?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Jennifer Murphy MS, RD, LDN

Clinical Dietician

Nutrition Consultation Form

EXERCISE:

Are you currently on an exercise program? Yes or No

If so, what specifically are you doing each day?

Sunday: ______________________________________________________________________

Monday: _____________________________________________________________________

Tuesday: _____________________________________________________________________

Wednesday: __________________________________________________________________

Thursday: ____________________________________________________________________

Friday: _______________________________________________________________________

Saturday: _____________________________________________________________________

Are you currently working with a Trainer or Coach? Yes or No If yes, who and when?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Have you ever played a sport? Yes or No If yes, which sport(s), when, and how long?

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Jennifer Murphy MS, RD, LDN

Clinical Dietician

Nutrition Consultation Form

NUTRITION LOG:

What did you eat and drink yesterday? Please include portion sizes and brands if it is possible.

I.e. 1 cup of Tropica a ora ge juice, 6 ou ces No Fat Da o Yogurt, etc…

Breakfast: Time: _________

Item(s): ______________________________________________________________________

_____________________________________________________________________________

Morning Snack: Time: __________

Item(s): ______________________________________________________________________

_____________________________________________________________________________

Lunch:Time: __________

Item(s): ______________________________________________________________________

_____________________________________________________________________________

Afternoon Snack: Time: ___________

Item(s): ______________________________________________________________________

_____________________________________________________________________________

Dinner: Time: ____________

Item(s): ______________________________________________________________________

_____________________________________________________________________________

Snack/Dessert: Time: _____________

Item(s): ______________________________________________________________________

_____________________________________________________________________________

Exercise: _____________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Jennifer Murphy MS, RD, LDN

Clinical Dietician

Nutrition Consultation Form

NOTES:

S:

O:

A/P:

Jennifer Murphy MS, RD, LDN

Clinical Dietician

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Filling out segment 1 in nutrition form printable

2. Right after the last section is filled out, go to type in the suitable information in these: What are your nutrition and, and What have you tried in the past to.

Completing part 2 of nutrition form printable

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Part # 3 for filling out nutrition form printable

4. This next section requires some additional information. Ensure you complete all the necessary fields - Please list any relevant past, Have you ever been diagnosed with, Yes or, At what age did you get your first, Do you get regular periods, Yes or, When was your last menstrual, Do you take any Vitamin Mineral, If yes please list below, Are there any foods that you avoid, and If yes please list below - to proceed further in your process!

Step number 4 in filling in nutrition form printable

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5. The final notch to submit this form is pivotal. You'll want to fill out the necessary blank fields, for instance Are you a Vegetarian, Yes or, If yes please circle which foods, chicken, fish, dairy, eggs, red meat, On average how many days a week do, On average how many alcoholic, What types of alcohol do you, Beer, Wine, Liquor, and Other, prior to using the pdf. Failing to accomplish that could lead to an incomplete and probably nonvalid document!

nutrition form printable completion process described (part 5)

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