# Nutrition Intake Form Template

> A free nutrition intake form for nutrition and health coaches. New clients share goals, eating habits, diet, allergies and lifestyle before the first call.

A nutrition questionnaire for new coaching clients that covers goals, a typical day of eating, dietary preferences, allergies, cooking, sleep, stress and movement, with a signature to confirm the answers.

Canonical: https://reuily.com/templates/nutrition-intake-form
Use this template: https://reuily.com/form/from-template/nutrition-intake-form
Collections: Requests & Intake, Coaching, Holistic Wellness
Last updated: 2026-10-24

## Questions

- Question 1: What's your full name? (Short Text, required)
- Question 2: What's your email address? (Email, required)
- Question 3: What's your phone number? (Phone, required)
- Question 4: What's your date of birth? (Date, required)
- Question 5: What are your main goals? (Multiple Choice, required). Options: More energy; Weight change; Better digestion; Eat more whole foods; Build healthy habits; Sports performance; Something else
- Question 6: Describe what you eat on a typical day (Long Text, required)
- Question 7: Do you follow a particular way of eating? (Single Choice, required). Options: No; Vegetarian; Vegan; Gluten free; Low carb or keto; Something else
- Question 8: Do you have any food allergies or intolerances? (Short Text, optional)
- Question 9: How many meals do you cook at home each week? (Single Choice, required). Options: 0 to 3; 4 to 7; 8 to 14; Almost all of them
- Question 10: How much water do you drink a day? (Single Choice, required). Options: Less than 4 glasses; 4 to 7 glasses; 8 or more glasses
- Question 11: How would you rate your stress most days? (Opinion Scale, required)
- Question 12: What medications or supplements do you take? (Long Text, optional)
- Question 13: What has made healthy eating hard for you before? (Long Text, optional)
- Question 14: Sign to confirm your answers (Signature, required)

Signing records the signer's consent, email, IP address, browser and signing time, and each signer can download a signed PDF copy.

## Common uses

- Nutrition coaches and nutritionists
- Health coaches
- Meal planning and wellness programs

## Key features

- Goals and a typical day of eating
- Diet, allergies and supplements
- Signature to confirm the answers

## Frequently asked questions

### What should a nutrition intake form include?

Goals, a typical day of eating, the way the client eats, allergies, cooking habits, water, stress, medications and supplements, and what has made healthy eating hard before.

### Does it work for health coaches too?

Yes. Health coaches use it as their intake form. Add questions on sleep or movement if your program covers them.

### When should I send it?

Right after a client signs up, so you can read their answers and come prepared to the first call. Add a Calendly or Cal.com question to book that call on the same form.