What to Include in a Dietitian Intake Form and Health History Questionnaire

A dietitian intake form should collect the contact, care-coordination, and administrative information needed to begin services; the health history questionnaire should capture medical, nutrition, and lifestyle factors that may affect care. For a US cash-pay practice, keep questions relevant, explain sensitive requests, and separate clinical history from consent and financial agreements.

Start with essential intake information

Include fields that help you identify the client, communicate appropriately, and understand why they are seeking care:

• Identification: name, name used, date of birth, and optional pronouns.
• Contact details: address, telephone number, email, preferred contact method, and whether messages may be left.
• Visit information: reason for the appointment, referral source, and primary goals.
• Care team: primary care clinician and relevant specialists, with contact information when coordination is anticipated.
• Accessibility: preferred language, interpreter needs, and communication or accommodation requests.
• Emergency contact: name, relationship, and telephone number, with a brief explanation of intended use.

For minors or clients with an authorized representative, collect the representative’s identity, relationship, and authority as appropriate. Consent, privacy, and confidentiality rules vary by state and circumstances; verify requirements rather than assuming a parent or caregiver always has unrestricted access.

Do not routinely request a Social Security number, insurance card, or unrelated identity information. If a client requests documentation for possible out-of-network benefits, collect only the additional details needed; never promise reimbursement.

Cover the health history that affects nutrition care

Use a focused questionnaire with checkboxes, brief explanations, and space for information the client considers important. Ask about:

• Medical conditions: current and past diagnoses, approximate diagnosis dates, treating clinicians, and relevant family history.
• Procedures and hospitalizations: especially gastrointestinal surgery, bariatric procedures, or events affecting appetite, absorption, mobility, or intake.
• Medications and supplements: prescription and over-the-counter medicines, vitamins, minerals, herbs, doses, frequency, and recent changes.
• Allergies and intolerances: the food or substance, reaction, severity, and whether it has been medically evaluated. Keep allergies distinct from preferences and intolerances.
• Symptoms: appetite changes, nausea, vomiting, reflux, abdominal pain, bowel changes, chewing or swallowing difficulties, and fatigue.
• Relevant measurements and tests: available laboratory results, dates, and sources; height and weight history when clinically appropriate; and unintentional changes.
• Life-stage considerations: pregnancy, lactation, menstrual history, growth, or aging-related concerns when relevant.

Distinguish client-reported information from verified records. Do not make new laboratory testing a routine prerequisite unless clinically justified and within your legal scope and practice arrangements; ordering tests and acting on results depend on state law, credentials, facility or collaborative agreements, and payer rules when applicable.

Ask about eating patterns and daily realities

The questionnaire should reveal what eating actually looks like, not simply whether the client follows a particular diet. Include:

• A typical day of meals, snacks, beverages, and meal timing.
• Cultural, religious, ethical, sensory, and personal food preferences.
• Grocery access, food security, cooking facilities, budget constraints, and who shops or prepares meals.
• Work or school schedule, sleep, physical activity, and caregiving responsibilities.
• Alcohol use and other substance use when relevant to nutrition care.
• Previous nutrition counseling, dietary restrictions, and what has or has not helped.
• The client’s priorities, anticipated barriers, and preferred starting point.

Ask neutrally about eating disorder history, restrictive eating, binge eating, compensatory behaviors, and distress around food or body image when relevant. Explain why you ask, allow discussion during the visit, and use appropriate screening tools and referral pathways within your competence. An intake questionnaire is not a diagnosis.

Keep consent, privacy, and payment documents distinct

An intake packet can contain several documents, but each should have a clear purpose:

• Service agreement or informed consent: describe services, limitations, communication expectations, and applicable telehealth arrangements.
• Privacy materials: if you are subject to HIPAA, provide required notices and obtain any required acknowledgment. A privacy acknowledgment is not a blanket authorization to disclose records.
• Information-sharing authorization: use a separate authorization when legally required, identifying the recipient, information, purpose, and applicable expiration.
• Financial policy: explain fees, payment timing, cancellation terms, and any charges for additional services.

Cash-pay status alone does not determine whether HIPAA applies. Whether HIPAA applies depends on whether you (or your group) meet the definition of a covered entity (or are a business associate) and transmit health information in a HIPAA-covered electronic transaction; state privacy laws may also apply. HHS explains the federal framework in its covered-entities guidance.

Uninsured or self-pay clients may have Good Faith Estimate rights under the federal No Surprises Act for certain items and services, depending on whether the provider or facility is covered by the law and the setting. A fee acknowledgment does not replace an estimate when an estimate is required. Review CMS guidance on uninsured and self-pay billing rights.

Practical intake-packet checklist

Before using your forms, confirm that you have:

• [ ] Separated required fields from optional or visit-discussion questions.
• [ ] Included “none,” “unsure,” and “prefer to discuss” where appropriate.
• [ ] Explained sensitive questions and avoided unnecessary data collection.
• [ ] Provided a secure submission method and restricted staff access appropriately.
• [ ] Assigned responsibility for reviewing forms before or during the appointment.
• [ ] Stated that forms and routine messages are not monitored for emergencies.
• [ ] Created a process to clarify concerning answers and arrange appropriate referrals.
• [ ] Added completion dates and a way to record updates.

Review and update the information

Confirm key answers with the client rather than copying them uncritically into the clinical record. Recheck medications, allergies, diagnoses, symptoms, and goals when circumstances change, and establish retention and disposal procedures.

No template makes a practice compliant. Requirements vary by state, license, setting, and payer; verify relevant obligations with your licensing board, payer when applicable, or a qualified legal or privacy professional.