--- title: "Free Dietitian & Nutrition Intake Form Template | formformform" description: "Free dietitian and nutrition intake form template. Covers reason for referral, a typical day of eating, allergies and intolerances, conditions and medications…" url: "https://www.formformform.com/templates/dietitian-nutrition-intake-form" type: static generatedAt: "2026-08-23T18:56:58.727Z" --- [Templates](https://www.formformform.com/form-templates)/[Healthcare Forms](https://www.formformform.com/form-templates/healthcare-forms) # Dietitian & Nutrition Intake Form Template Most nutrition intake forms open by demanding a height and a weight. This one opens by asking what you would like help with, and asks whether weight should be part of the conversation at all before asking for a number — which stays optional. Underneath, it collects what a dietitian actually needs to give advice someone can follow: a typical day of eating, allergies and intolerances, conditions and medications, and the practical realities of budget, shopping, cooking facilities and cultural or religious requirements. [Use this template](https://app.formformform.com/templates/dietitian-nutrition-intake-form/use) Last updated 21 August 2026 ## Fields in this template - Full Name · required - Date of Birth - Email Address · required - Phone Number - How did you come to us? · required I referred myself · My GP or doctor referred me · A hospital consultant or team referred me · Another health professional referred me · Through my workplace or an employer scheme · Through my insurance · Someone recommended you - Referring Professional's Name, If There Was One - What would you like help with? · required - What is this appointment about? A condition I have been told to eat differently for · Digestive symptoms · Managing blood sugar · Blood pressure or cholesterol · Low iron, vitamin D or another deficiency · Food allergies or intolerances · Not eating enough, or losing weight without meaning to · Weight management · Sport or training nutrition · Pregnancy, or feeding a baby · Feeding a child, or fussy eating · Planning a vegetarian or vegan diet well · Recovering from illness, surgery or treatment · Tiredness or low energy · General healthy eating · Something else — I will explain in the appointment - Would you like weight to be part of what we discuss? · required Yes, I would like to talk about weight · Only if it is clinically necessary · No — I would rather we did not · I am not sure yet - Current Weight, If You Want to Share It - Height, If You Know It - Have there been any recent changes in your weight or appetite? - A typical day of eating · required - How much does a typical day vary? Most days look fairly similar · Weekdays and weekends are very different · It changes with my shifts or my work pattern · It is unpredictable — it depends how the day goes - Food allergies · required - Foods that reliably cause you symptoms Dairy or lactose · Gluten or wheat · Onion, garlic or other high-FODMAP foods · Beans and pulses · Spicy food · Fatty or fried food · Caffeine · Alcohol · Artificial sweeteners · Fizzy drinks · Nothing I have noticed · Something not listed here - Medical conditions that affect what you eat Type 1 diabetes · Type 2 diabetes · Gestational diabetes · Prediabetes · High blood pressure · High cholesterol · Coeliac disease · Irritable bowel syndrome · Crohn's disease or ulcerative colitis · Reflux or indigestion · Kidney disease · Liver disease · A thyroid condition · PCOS · Cancer, or cancer treatment · Surgery that changed how I eat or digest · Difficulty chewing or swallowing · Currently pregnant or breastfeeding · Poor dental health affecting what I can eat · None of these · I would rather discuss this in the appointment - Anything you would like to add about those conditions - Medications · required - Supplements, vitamins, herbal or protein products - Getting hold of food I can usually buy the food I want · I am careful with a tight food budget · I sometimes run out of food before the end of the week · I use a food bank or another food support service · Getting to a shop is difficult for me · I rely on someone else to shop for me · I mostly rely on deliveries or takeaways · I would rather not answer this - Cooking facilities you have Oven · Hob or stovetop · Microwave · Air fryer or slow cooker · Kettle only · Fridge · Freezer · A shared kitchen · No reliable cooking facilities - How confident do you feel cooking? Not at all confident · Slightly confident · Moderately confident · Very confident · I cook from scratch without thinking about it - Who usually does the cooking where you live? I do · Someone else does · We share it · It varies · Meals are provided — care home, canteen or a delivered meals service - Cultural, religious or ethical dietary requirements - What would a good outcome look like for you? · required - Anything else you would like us to know before we meet? - Communication or access needs for your appointment - Before You Submit · required I understand this form is used to prepare for my appointment, that it is not a request for urgent or emergency care, and that nobody may read it before I am seen. ## Who uses this template Registered dietitians in private practice · Hospital and community dietetic services · Diabetes and cardiac rehabilitation teams · Gastroenterology and IBS services · Oncology and post-surgical nutrition support · Renal dietetic services · Paediatric and family nutrition services · Weight-inclusive and non-diet practitioners · Sports nutrition practitioners working alongside a clinical team ## About this template A dietitian's first appointment turns on two things: what someone actually eats, and what they are realistically able to change. A form that opens with a required weight and a required height collects neither, and it sets a tone that makes the first answer less honest than it needed to be. This template is built the other way round. It asks what the person wants help with, then asks — as a required question — whether they want weight to be part of the conversation at all. Only then does it offer a weight field, optional, in free text, in whatever units they think in. The centre of the form is a typical day of eating, written as prose rather than as a food frequency grid, with wording in the field that says plainly there are no right answers. Around it sits the clinical context a dietitian needs to give safe advice: allergies and medications, both required with the reason stated; conditions that affect eating; supplements and herbal products asked separately from prescriptions because they are so consistently forgotten. Then the part most nutrition forms leave out entirely — whether food is affordable, whether getting to a shop is possible, what cooking facilities exist, how confident the person feels cooking, who does the cooking, and what cultural, religious or ethical requirements apply, including fasting periods rather than only foods. Advice that assumes an oven, a car and an unlimited budget is advice nobody follows. This form deliberately contains no eating disorder screening questions, and the field notes say so. Validated screening tools need clinical governance, a trained assessor and a defined route for a positive result; a self-serve web form has none of those, and running a screening battery without them does more harm than not screening at all. Screening belongs inside your clinical pathway. More broadly, this is a template rather than a validated instrument — have a registered dietitian review and adapt it before you use it with clients. formformform hosts every form in the EU and handles submissions under GDPR, and end-to-end encryption is an opt-in switch on your own copy. Neither the template nor the platform makes any service compliant with HIPAA, SOC 2, ISO 27001 or any other framework, and providers are responsible for validating their own legal and regulatory requirements. ## 13 form ideas you can build with this template ### Private Dietitian First Appointment Intake Collect a typical day of eating, the clinical context and the practical constraints before a first paid consultation. ### Weight-Inclusive Practice Intake Form Delete the weight and height fields entirely and keep the framing question, so a client's first experience of the service is being asked rather than measured. ### Diabetes Dietetic Service Intake Pair the medication field with the meal timing and fasting questions before a blood-sugar-focused first appointment. ### IBS and Digestive Health Intake Form Use the symptom-trigger checklist and the typical-day field to prepare a gastroenterology dietetic session. ### Oncology Nutrition Support Intake Record appetite change, swallowing difficulty and unintentional weight change ahead of a nutrition support appointment. ### Renal Dietitian Intake Form Switch the weight field to required with a stated clinical reason, and keep the medication, supplement and fluid-relevant questions. ### Community Nutrition Programme Intake Keep the food access and cooking facilities fields for a service that can signpost to practical food support. ### Corporate Wellbeing Nutrition Intake Use the shift-pattern variation question for employees whose eating changes completely between working and rest days. ### Paediatric Feeding Intake Form Let a parent describe a typical day and the family's cultural requirements before a first appointment about a child's eating. ### Vegan and Vegetarian Diet Planning Intake Combine the cultural and ethical requirements field with the supplements question for a planning-focused consultation. ### Sports Nutrition Clinical Intake Use the typical-day and supplement fields together for an athlete whose protein and pre-workout products are otherwise never mentioned. ### Post-Surgical Nutrition Intake Form Record surgery that changed digestion, chewing or swallowing alongside current intake before a follow-up appointment. ### Telehealth Dietitian Intake Form Use the access needs field to arrange a video consultation and gather everything a remote first appointment would otherwise spend half its time asking. ## What's included Weight framed as a choice — a required question about whether to discuss it at all comes before an optional, free-text weight field Height and weight as free text with units the client chooses, rather than required numeric fields feeding an automatic BMI A typical day of eating as the central required field, with wording that removes the pressure to write an idealised answer Food access and budget asked directly, with a 'rather not answer' option and a note to delete the field if the service cannot act on it Cooking facilities, cooking confidence and who does the cooking asked separately, so advice matches the kitchen that exists Cultural, religious and ethical requirements given their own field, including fasting periods as well as foods Allergies and medications required, with the clinical reason stated in the field itself Supplements and herbal products asked apart from medication, because they are routinely forgotten No eating disorder screening battery, and a field note explaining why that belongs in a governed clinical pathway instead Prominent emergency notice above every question Free with unlimited submissions, hosted in the EU, with optional end-to-end encryption per form ## How to create a dietitian & nutrition intake form 1. 1 Click "Use this template" to load the dietitian and nutrition intake form into your free formformform account. 2. 2 Have a registered dietitian review and adapt the wording before you publish it, and confirm it fits your service's clinical governance. 3. 3 Do not add an eating disorder screening battery. If your service screens, run it inside a supervised clinical pathway with a defined route for a positive result — not on an intake form. 4. 4 Decide what your service actually needs from the weight questions. A diabetes or renal service may need a weight for calculations and should say so in the field; a weight-inclusive practice can delete the weight and height fields entirely and keep only the framing question. 5. 5 Delete the food access field if your service cannot act on the answer or signpost anywhere useful — asking about food insecurity and doing nothing with it is worse than not asking. 6. 6 Adapt the conditions checklist to your caseload. A renal service, a paediatric service and an IBS service will each keep a very different subset. 7. 7 Add conditional logic in the editor if you want follow-up questions to appear only for certain answers — templates cannot ship with branching, so add the rules after cloning. 8. 8 Turn on end-to-end encryption in your account settings before you share the link, so answers are sealed in the client's browser before they are stored. 9. 9 Share the link on the booking confirmation and set a notification so the dietitian reads it before the appointment. ## Best practices for your dietitian & nutrition intake form Have a registered dietitian sign this off before it goes live. It is a starting point written to be adapted, not a validated assessment tool, and the wording should match your service's governance and scope of practice. Ask about weight before you ask for it. The required framing question is the most important field on the form it lets someone opt out of a weight conversation without having to raise it themselves, and it changes how you open the appointment. Leave the weight and height fields optional and in free text. A required numeric weight feeding an automatic BMI number is the single most common reason people abandon a nutrition intake form, and an estimate in the client's own units is more useful than a blank field. Say in the form that nothing is judged, and mean it. The typical-day field only produces a useful answer if the person believes they are not being marked, so keep that wording rather than trimming it for length. Never add eating disorder screening to an intake form. Validated tools require a trained assessor, supervision and a defined response pathway; without those, a positive screen has nowhere to go. Keep screening inside your clinical pathway. Only ask about food insecurity if you can do something with the answer. The field ships with a 'rather not answer' option and a note to delete it otherwise collecting it and ignoring it is worse than never asking. Ask about the kitchen, not just the diet. Cooking facilities, confidence and who does the cooking are three separate questions because a meal plan that assumes an oven and an hour is useless to someone with a microwave and a night shift. Treat fasting as timing, not as a preference. The cultural and religious field asks for fasting periods explicitly, because timing interacts with medication and blood sugar in ways a list of avoided foods does not show. Turn on end-to-end encryption before sharing the link. Diet, weight, conditions, medication and food insecurity are all sensitive encryption is opt-in per form and freezes once the first response arrives, so enable it first. Validate your own compliance obligations separately. Nothing here makes a practice HIPAA compliant or represents any certification. ## Frequently asked questions Is this dietitian intake form template free? Yes. Use it, customise it and collect unlimited submissions at no cost, with no per-submission fees. Can I use this form as it is? Not without review. It is a starting point written to be adapted, not a validated instrument — have a registered dietitian check it against your service's clinical governance and scope of practice before you publish it. Why is weight optional? Because a required weight field costs more honest answers than it gains data. The form asks first whether the client wants weight discussed at all, then offers an optional free-text field. Services that genuinely need a weight for calculations can switch the field to required and say why in the field description. Why is there no eating disorder screening section? Because screening needs clinical governance that a self-serve form cannot carry — a trained assessor, supervision, and a defined route for what happens when someone screens positive. Running a validated battery without those is worse than not screening. Keep screening inside your clinical pathway; this form is intake. Why does it ask about my food budget and my kitchen? Because advice that assumes an unlimited budget, an easy trip to a supermarket and a full kitchen is advice nobody can follow. Both questions have a 'rather not answer' option, and the food access field carries a note telling services to delete it if they cannot act on the answer. How is this different from the nutrition consultation request template? The nutrition consultation request form is a fitness-category enquiry form: it requires height, weight and date of birth for a caloric baseline, and stops at goals, restrictions and eating habits. This one is a clinical intake — weight is optional and framed as a choice, and it adds referral source, medications, supplements, food access and budget, cooking facilities, cooking confidence and cultural or religious requirements, none of which the consultation request asks. Can clients send a food diary or a blood test result? Not on this template as it ships, because templates cannot include an upload field. Add an Upload field to your own copy in the form editor — formformform supports uploads on any form at up to 2 MB per file, and files stay encrypted on end-to-end encrypted forms. Is this form HIPAA compliant? No form makes a practice HIPAA compliant on its own. formformform hosts in the EU, handles submissions under GDPR, and offers optional end-to-end encryption per form. 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