Nutrition Consultation Form

Nutrition Consultation Form - User Guide

This user guide will help you understand how to properly fill out the Nutrition Consultation Form to ensure you get the most effective nutritional advice.

Overview

The Nutrition Consultation Form is designed to gather comprehensive information about your health status, dietary habits, and lifestyle to help a nutrition professional provide personalized recommendations.

How to Complete the Form

Personal Information Section

• Full Name: Enter your legal first and last name
• Date of Birth: Use format MM/DD/YYYY
• Gender: Select the option that best represents you
• Contact Information: Provide your current phone number and email address
• Address: Include your complete mailing address
• Emergency Contact: Provide the name and phone number of someone we can contact in case of emergency

Health Information Section

• Height and Weight: Be as accurate as possible for proper assessment
• Medical Conditions: Check all that apply to you
• Medications/Supplements: List all prescription medications, over-the-counter drugs, and supplements with their dosages
• Health Goals: Be specific about what you hope to achieve (e.g., "lose 15 pounds," "improve digestion," "have more energy")

Dietary Habits Section

• Current Diet Type: Select the category that best describes your eating pattern
• Typical Meals: Describe what you typically eat for each meal - be honest rather than idealistic
• Food Preferences/Restrictions: Note any dietary restrictions, whether medical, ethical, or personal
• Food Dislikes: Mention foods you avoid due to taste or texture preferences
• Beverage Consumption: Estimate your typical intake of water, caffeine, and alcohol

Lifestyle Information Section

• Activity Level: Select the description that best matches your routine
• Exercise Details: Specify what types of exercise you do and how often
• Sleep Habits: Describe your typical sleep patterns and any issues
• Stress Levels: Honestly assess your typical stress level
• Occupation: Note your job as it may impact your eating patterns

Additional Information Section

• Nutrition Challenges: Identify what you find most difficult about eating well
• Cooking Habits: Be honest about your food preparation skills and habits
• Eating Out Frequency: Note how often you consume restaurant or takeout food
• Food Budget: Share your typical weekly food spending if comfortable doing so
• Additional Information: Include anything else you think might be relevant

Consent and Authorization

• Read the disclaimer carefully
• Provide your signature and date (if filling out a physical copy)

Tips for Completion

1. Be thorough: The more information you provide, the better personalized your nutrition plan will be
2. Be honest: Don't report "ideal" behaviors - share your actual habits for accurate assessment
3. Take your time: Set aside 15-20 minutes to complete the form thoughtfully
4. Prepare information: Have your medication names and dosages handy before starting
5. Ask for help: If you're unsure about any section, ask for clarification

After Submission

Once you submit your form:

1. A nutrition professional will review your information
2. You'll typically schedule a follow-up consultation to discuss your plan
3. Bring any additional medical records or lab results to your consultation

Privacy Information

Your personal health information is kept confidential and is only used to develop your personalized nutrition plan.

Technical Notes

• Use the "Print Form" button to create a physical copy if needed
• The form is designed to print neatly on standard letter-size paper
• Digital submissions may vary based on your practitioner's preferred method

If you have any questions while completing the form, don't hesitate to contact your nutrition professional for assistance.