Meal Intake Form

Personal Information:

Name

Date Of Birth

Address

Gender

Male

Female

City

State

Zip

Phone

Email Address

Emergency Phone

Emergency Email Address

Health Information

Height (in feet and inches)

Current Weight (in pounds)

Desired Weight (in pounds)

Are you currently under the care of a healthcare provider?

Yes

List any chronic health conditions or medical history relevant to weight management? (e.g., diabetes, heart disease, arthritis, etc.)

Are you taking any medications or supplements?

Yes

Do you have any food allergies or dietary restrictions?

Yes

How many meals do you typically eat in a day? (e.g., breakfast, lunch, dinner, snacks)

Current Eating Habits

How would you describe your typical daily meals? (e.g., breakfast, lunch, dinner)

Do you have any favorite or preferred foods?

Yes

How frequently do you consume snacks and sugary beverages?

How many servings of fruits and vegetables do you consume daily?

Do you drink alcohol?

Yes

Do you have any cultural or religious dietary preferences that should be considered?

Yes

Lifestyle and Activity Level

How would you rate your current physical activity level? (e.g., sedentary, moderately active, very active)

Do you have any specific preferences for meal preparation methods? (e.g., oven-baked, grilled, steamed, etc.)

Are there any mobility issues that may affect your ability to prepare meals or eat certain foods?

Yes

Previous Dietary Experience

Have you worked with a dietitian or nutritionist before?

Yes

Have you followed any specific diets or meal plans in the past? (e.g., low-carb, Mediterranean, vegetarian, etc.)

What was your experience with previous dietary attempts? (e.g., challenges, successes, etc.)

By submitting this form, I acknowledge that the information provided in this intake form is accurate and complete to the best of my knowledge. I authorize the healthcare provider and the dietitian/nutritionist to use this information for the purpose of creating a personalized diet and meal plan tailored to my health and dietary goals.

Please note that this form is intended for informational purposes and does not replace personalized medical or nutritional advice. The information provided will be used to create a tailored diet and meal plan in collaboration with the healthcare provider and the dietitian/nutritionist.

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Diet and Meal Plan Intake Form