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Nutrition Care Plan Form Template

Streamline Nutritional Care with Our Template

Creating a personalized nutrition care plan can be overwhelming, but our template simplifies the process for healthcare providers. This nutrition care plan form helps you establish clear dietary needs and goals for your patients, ensuring they receive tailored support. Utilize our template for effective communication among care teams, improved patient outcomes, and easy tracking of dietary progress, while maintaining compliance with WCAG-aligned standards. Explore how our live template can transform your nutritional care process.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
What are your primary nutrition goals?
Please Specify:
Top priority goal for the next 8-12 weeks
Current medications and supplements (name and dose if known)
Known food allergies or intolerances
Have you been diagnosed with any of the following conditions?
Please Specify:
Which dietary patterns or preferences apply to you?
Please Specify:
How often do you eat home-cooked meals?
Very rarely
Rarely
Sometimes
Often
Very often
Describe a typical day of meals and snacks
On a typical day, how much water do you drink?
Less than 4 cups (under 1 liter)
4-6 cups (1-1.5 liters)
7-9 cups (1.75-2.25 liters)
10+ cups (2.5+ liters)
Not sure
How often do you drink alcohol?
Very rarely
Rarely
Sometimes
Often
Very often
Do you currently smoke or vape?
Yes
No
Physical activity level
Sedentary (little or no exercise)
Lightly active (1-3 days/week)
Moderately active (3-5 days/week)
Very active (6-7 days/week)
Prefer not to say
Average nightly sleep duration
Less than 5 hours
5-6 hours
7-8 hours
9+ hours
Varies
Prefer not to say
How often do you experience digestive discomfort (e.g., bloating, gas, heartburn)?
Very rarely
Rarely
Sometimes
Often
Very often
Current weight (please include units)
Height (please include units)
Target outcomes or metrics you want to achieve
Relevant recent lab results (e.g., A1c, lipids) and dates, if available
Weight change over the past 3 months
Lost weight
No change
Gained weight
Not sure
Prefer not to say
Preferred consultation format
In-person
Video call
Phone
No preference
Best days and times for appointments
I consent to nutrition assessment and development of a nutrition care plan
Yes
No
Name (as signature)
Date
I understand that nutrition counseling does not diagnose or treat disease and is not a substitute for medical care
Strongly disagree
Disagree
Neither
Agree
Strongly agree
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Paper art illustration featuring a nutrition care plan form with sections for dietary information and health goals.

When to use this form

Use this template when you need to build or update a personalized nutrition plan at intake, after a hospital stay, or when weight, appetite, or labs change. It helps you and your team capture goals, risks, and next steps in one place. Create clear meal, hydration, and supplement actions, set follow-ups, and share tasks with family. For families exploring services, the Home care inquiry form helps you collect contacts and preferences before planning. If the person receives palliative services, align choices with the Hospice care checklist form. For home-based cases, pair this with a Home health assessment form to address mobility, swallowing, or shopping barriers that affect eating. The outcome: safer intake and realistic goals you can track.

Must Ask Nutrition Care Plan Questions

  1. What are your top nutrition and health goals for the next 30-90 days?

    Clear goals make the plan measurable and focused. A timeline helps you set follow-ups and judge progress.

  2. Which medical conditions, symptoms, or allergies affect what you can eat or drink?

    This protects safety and ensures the plan fits your diagnosis and symptoms. It guides textures, fluids, and nutrient targets.

  3. What is your current weight, usual weight, and any change in the last 1-3 months?

    Weight trends show risk of malnutrition or fluid retention. They inform calorie and protein needs.

  4. How do mobility, chewing, or swallowing issues affect shopping, cooking, and meals?

    Functional limits shape realistic meal plans and textures. Knowing barriers lets you add aids, caregiver help, or delivery options.

  5. What foods, textures, and cultural or religious preferences should we honor?

    Preference-based plans improve intake and respect values. This increases comfort and adherence.

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