Nutrition Intake Form Template – Canada

The Nutrition Intake Form Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. Each version is customizable and ready for printing, ensuring they fit your requirements perfectly.

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Nutrition Intake Form Template – Canada

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1. Client Information



2. Medical History

3. Current Medications

4. Lifestyle Information

5. Nutritional Preferences

6. Goals and Objectives

7. Dietary Habits

8. Additional Notes

9. Consent and Acknowledgment



PDF

WORD

Examples

Nutrition Intake Form Template – Canada (1)
Client Information:
[Client’s Name]
[Client’s Age]
[Client’s Address]
[Client’s Phone]
[Client’s Email]
Date:
[Date of Completion]
Health History:
Please list any medical conditions, allergies, or medications that are currently affecting your health:
[Health Conditions]
Current Diet:
Describe your typical daily diet, including meals and snacks:
[Diet Description]
Preferred Food Groups:
Indicate your preferred food groups (e.g., fruits, vegetables, grains, proteins, dairy):
[Preferred Food Groups]
Physical Activity Level:
Describe your physical activity level (e.g., sedentary, moderate, active):
[Activity Level]
Goals:
What are your nutritional goals? (e.g., weight loss, muscle gain, improved energy):
[Goals]
Dietary Preferences:
Do you have any dietary restrictions or preferences? (e.g., vegetarian, vegan, gluten-free):
[Dietary Restrictions]
Additional Comments:
Please provide any additional information or comments about your nutrition intake:
[Additional Comments]
Nutrition Intake Form Template – Canada (2)
Client Information:
[Client’s Name]
[Client’s Age]
[Client’s Address]
[Client’s Phone]
[Client’s Email]
Date:
[Date of Completion]
Health Background:
Please list any chronic illnesses, allergies, or medications you are currently taking:
[Health Background]
Typical Food Intake:
List your meals and snacks for a typical day:
[Food Intake]
Food Choices:
What types of foods do you prefer? (e.g., types of fruits, vegetables, meat alternatives):
[Food Choices]
Physical Activity:
Describe your level of physical activity (e.g., light, moderate, vigorous):
[Physical Activity]
Nutritional Objectives:
What are your objectives regarding nutrition? (e.g., lose weight, improve health, balance diet):
[Nutritional Objectives]
Food Restrictions:
Do you have any food allergies or dietary restrictions to note?
[Food Restrictions]
Further Information:
Please add any further notes or information regarding your nutrition:
[Further Information]

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Nutrition Intake Form Template - Canada