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Dietary Assessment Form Template

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Client Details

Diet Information

Physiological Info

Lifestyle Habits

Medical History

The Dietary Assessment Form Template by WPForms helps nutritionists, dietitians, and health coaches in need of an efficient way to assess clients’ dietary habits.

How Does the Dietary Assessment Form Template Work?

The Dietary Assessment Form Template requires the WPForms Basic License since it uses numerous Fancy Fields to capture detailed dietary information easily. Fields include:

  • Client Details:
    • Name: Records the individual’s full name for personal identification.
    • Gender: Helps tailor dietary advice based on gender-specific nutritional needs.
    • Date of Birth: Important for age-related dietary recommendations.
    • Email Address: For sending dietary analyses, plans, and follow-ups.
  • Diet Information:
    • Current Diet Pattern: Provides insight into the individual’s typical eating habits.
    • Meal Frequency: Captures how often the person eats for metabolism details.
    • Dietary Restrictions: Identifies any foods the individual avoids or doesn’t eat.
    • Food Preferences: Highlights preferred foods to tailor enjoyable dietary plans.
    • Favorite Foods: Helps in understanding the individual’s tastes.
    • Least Favorite Foods: Ensures recommended diets avoid these items.
  • Physiological Info:
    • Weight Goals: Sets the foundation for goal-oriented nutritional planning.
    • Current Weight: Essential for calculating dietary needs and monitoring progress.
    • Height: Used in conjunction with weight to assess body mass index (BMI).
    • Exercise Routine: Provides context on physical activity levels, influencing dietary needs.
  • Lifestyle Habits:
    • Smoking Habits: Insights into lifestyle factors that affect dietary requirements.
    • Alcohol Consumption: Impacts nutritional planning and health goals.
    • Drug Addiction: Critical for addressing specific nutritional interventions.
    • Fluid Intake: Monitors hydration levels, an important aspect of overall health.
  • Medical History:
    • Current Health Conditions: Any conditions that require dietary adjustments.
    • Allergies: Essential for avoiding adverse food reactions.
    • Medications Being Taken: Some medications interact with certain foods.
    • Previous Surgeries: Past medical interventions can influence dietary needs.

Sign up with WPForms today and access the Dietary Assessment Form Template to deepen your understanding of an individual’s dietary habits.