Nutrition Intake Form
Dietetic intake covering what the patient eats in a typical day, symptoms, relevant conditions and medication, and the goal they want to work on.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 19 questions, 2 pages, 3 conditional rules.
- Questions
- 19
- Pages
- 2
- Layouts
- classic · card
- Time to complete
- ≈ 6 min
- Conditional rules
- 3
Searches this template answers
- nutrition intake form
- dietitian intake form template
- diet history form
- nutrition assessment form online
- dietetic referral intake form
- food diary intake form
Also filed under
Live preview and test console
This is the real form. Answer it to test the flow — nothing is sent or stored.
Page 1 of 2 — A typical day
This template runs as a straight sequence — no branching rules.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Nutrition Intake Form is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 19 questions across 2 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 12 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- It captures a numeric value you can filter and sort on.
- Conditional logic hides 3 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 2 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Nutrition Intake Form lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 5Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 3 conditional rules ship with it.
- Features conditional validation: if “Has your weight changed in the last six months?” is Yes, “How much, and was it intended?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Do you avoid any foods?” is Yes, “Which foods, and why?” becomes mandatory before the form can be sent.
- Features conditional validation: if “Do you cook for yourself?” is No, “Who prepares your food?” becomes mandatory before the form can be sent.
- All 3 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
A first dietetic appointment usually starts by reconstructing what someone actually eats, which is slow and easy to get wrong from memory. This intake asks for a typical day in the patient's own words — breakfast, lunch, evening meal, snacks, drinks — before the appointment, alongside how many meals are eaten out or delivered in a week and who does the cooking. Practical questions about budget, cooking facilities and shift patterns are included because a plan that ignores them will not be followed. The clinical section covers relevant diagnoses, current medication and supplements, digestive symptoms, weight change and whether it was intended, food avoidances and the reason for each, and any allergy or intolerance that has been formally diagnosed. The last page asks what the patient wants to work on and what they have already tried, which frames the consultation around their goal rather than a generic plan. Nothing here recommends a diet or interprets symptoms; that is the dietitian's work once the picture is on the page.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — A typical day
- Full namerequired
- Date of birthrequired
- A typical breakfastrequired
- A typical lunchrequired
- A typical evening mealrequired
- Snacks and drinks through the dayrequired
- Meals eaten out or delivered in a weekrequired
- Do you cook for yourself?required
- Who prepares your food?
Page 2 — Health and goals
- Relevant diagnoses
- Current medication and supplements
- Any of these symptoms?required
- Has your weight changed in the last six months?required
- How much, and was it intended?
- Do you avoid any foods?required
- Which foods, and why?
- Diagnosed allergy or intolerance
- What would you like to work on?required
- What have you already tried?
19 questions in total.
Example of a completed nutrition intake form
A sample intake showing how a patient describes a typical day's eating before a first dietetic appointment.
- Full name
- Renata Silva
- Date of birth
- 26/01/1993
- A typical breakfast
- Toast with jam and a cup of coffee
- A typical lunch
- Sandwich from the canteen, crisps
- A typical evening meal
- Pasta with a jarred sauce, sometimes with vegetables
- Do you cook for yourself?
- Sometimes
- Has your weight changed in the last six months?
- Yes
- How much, and was it intended?
- Gained a few kilograms, not intended
- What would you like to work on?
- Eating more regularly and cutting back on takeaways
Sample data — no real people, addresses or records are shown.
How the form changes as it's filled in
This template ships with 3 conditional rules, grouped into 3 behaviours driven by 3 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Has your weight changed in the last six months?”
- Makes answers required
If “Has your weight changed in the last six months?” is Yes, “How much, and was it intended?” becomes required before the form can be submitted.
Driven by “Do you avoid any foods?”
- Makes answers required
If “Do you avoid any foods?” is Yes, “Which foods, and why?” becomes required before the form can be submitted.
Driven by “Do you cook for yourself?”
- Makes answers required
If “Do you cook for yourself?” is No, “Who prepares your food?” becomes required before the form can be submitted.
Set it up step by step
- 1
Ask for a typical day, not a diary
Four open boxes filled in honestly beat a seven-day diary abandoned on day two, and they arrive before the appointment.
- 2
Keep the practical questions
Cooking facilities, budget and shift patterns decide whether advice survives contact with the patient's week.
- 3
Separate diagnosed intolerance from avoidance
Both matter and they are not the same, which is why the form asks the reason behind every avoided food.
- 4
Open with the patient's goal in the room
Starting the consultation from their stated goal makes the plan theirs rather than something handed over.
Mistakes to avoid
- Requiring a full food diary up front, which lowers completion and delays the first appointment.
- Recording avoided foods with no reason, so a preference and a diagnosed allergy look identical.
- Writing a plan that assumes a kitchen, time and budget the patient never said they had.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Read the typical day before the appointment, build the plan around the patient's stated goal and constraints, and use the same questions at review to see what actually changed.
Works in both layouts
Forms that overlap this one
These pages cover the same subject ground as the nutrition intake form, matched on the words people actually search for.
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assessmentclinicclinicalhealthhistory
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Caregiver Assessment Form
assessmentclinicclinicalhealthhistory
Physiotherapy Intake Form
assessmentclinicclinicalcoveringgoal
Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Should we ask for a food diary as well?
Ask for one after the first appointment, when the patient knows why it helps. Requiring it before you have met tends to produce either nothing or a tidied-up version.
Is this suitable for paediatric dietetics?
Partly. A parent can complete it, but growth, feeding history and school meals need their own questions, so start from the Pediatric Intake Form and add these.
Does the form give any dietary advice?
No. It gathers what the patient reports and wants to work on; every recommendation comes from the dietitian in the consultation.
How do we use it at review?
Send the same form again and compare the typical-day answers. Change in the patient's own description is the outcome measure most patients recognise.
Is the Nutrition Intake Form template free to use?
Yes. You can preview and test Nutrition Intake Form on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Nutrition Intake Form template ask for?
It asks 19 questions across 2 pages, 12 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Nutrition Intake Form form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
3 conditional rules ship with the template: Features conditional validation: if “Has your weight changed in the last six months?” is Yes, “How much, and was it intended?” becomes mandatory before the form can be sent. Features conditional validation: if “Do you avoid any foods?” is Yes, “Which foods, and why?” becomes mandatory before the form can be sent. Features conditional validation: if “Do you cook for yourself?” is No, “Who prepares your food?” becomes mandatory before the form can be sent. All rules are editable in the Logic tab.
Where do responses to the Nutrition Intake Form form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Nutrition Intake Form form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
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