Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Nutritional Assessment Questionnaire Form Template

Discover how to empower your nutrition program with effective assessments

Are you struggling to gain a clear picture of your patients' eating habits? This Nutritional Assessment Questionnaire Template is designed to help healthcare providers like you evaluate dietary patterns effectively. By utilizing this user-friendly form, you can gather essential information on blood sugar levels, fatty acid intake, inflammation markers, and overall nutrition habits, leading to better health outcomes. Enhance your patient understanding, support tailored nutritional advice, and streamline the assessment process to improve care quality. Try out the live template to see how it works!

Use this Template (FREE) Live Preview
Full name
Email address
Age
Under 18
18-24
25-34
35-44
45-54
55-64
65+
Height (please include units, e.g., cm or ft/in)
Current weight (please include units, e.g., kg or lb)
Gender identity
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Have you been diagnosed with any of the following?
Please Specify:
Are you currently pregnant or breastfeeding?
Yes
No
Not applicable
Prefer not to say
Please list any prescription medications or regular over-the-counter drugs you take
Please list any vitamins or supplements you take (if any)
Known food allergies or intolerances
Please Specify:
Primary dietary pattern
Please Specify:
How many meals do you typically eat per day?
1
2
3
4
5 or more
How often do you eat takeout or restaurant meals?
Never
Rarely
Sometimes
Often
Always
How much water do you usually drink per day?
0-2 cups
3-4 cups
5-6 cups
7-8 cups
9+ cups
How often do you drink alcohol?
Never
Monthly or less
2-4 times a month
2-3 times a week
4+ times a week
Prefer not to say
Please describe a typical day of eating and drinking for you
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)
Athlete/physical job
Bloating
Very rarely
Rarely
Sometimes
Often
Very often
Irregular bowel movements (constipation or diarrhea)
Very rarely
Rarely
Sometimes
Often
Very often
Heartburn or acid reflux
Very rarely
Rarely
Sometimes
Often
Very often
Low energy or fatigue
Very rarely
Rarely
Sometimes
Often
Very often
What are your primary nutrition and health goals?
Please Specify:
How likely are you to make nutrition changes in the next 30 days?
Very unlikely
Unlikely
Neutral
Likely
Very likely
How easy would it be for you to follow a nutrition plan right now?
Very difficult
Difficult
Somewhat difficult
Neither easy nor difficult
Somewhat easy
Easy
Very easy
Typed full name (acts as signature)
Date
I consent to the collection and processing of this information for nutritional assessment purposes.
Yes
No
{"name":"Full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Full name, Email address, Age","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a nutritional assessment questionnaire form with food icons and health symbols

When to use this form

Use this form before a first nutrition consult, annual wellness visit, or program intake. It helps you capture diet history, allergies, symptoms, and goals so you can build a clear, personalized plan. Dietitians can send it to new clients; clinics can add it to pre-visit packets; coaches can use it to track progress over time. If you need a broader picture of lifestyle and risks, pair it with the Self-health assessment form. For medical background such as diagnoses, surgeries, or family history, reference the Statement of health form. The result is faster appointments, fewer follow-ups, and smarter recommendations.

Must Ask Nutritional Assessment Questionnaire Questions

  1. What do you typically eat and drink in a usual day (meals, snacks, and portions)?

    A detailed 24-hour pattern reveals nutrient gaps, excesses, and habits you can target. Portion clues help you quantify calories, fiber, and protein for a realistic plan.

  2. Do you have any food allergies or intolerances, and what reactions do they cause?

    This prevents unsafe recommendations and guides substitutions that fit your needs. Noting reactions and severity also flags when you may need testing or referral.

  3. What medical conditions, diagnoses, or medications could affect your nutrition?

    Health issues like diabetes, GERD, or anemia change energy and micronutrient needs and can interact with supplements. Cross-checking with the Doctor diagnosis form keeps your plan aligned with current care.

  4. How much water and other beverages do you drink each day (type and amount)?

    Hydration influences appetite, headaches, and performance, so it shapes meal timing and sodium needs. Beverage types add hidden sugars, caffeine, or alcohol you should account for.

  5. Have you had any recent weight change or appetite issues in the past 3 months?

    Unintentional loss or gain can signal malnutrition, fluid shifts, or medication effects. Timing helps you spot trends and decide on labs, referrals, or a higher level of screening.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel