Hi everyone,

as part of my online nutrition studies, I've been asked to develop a pre-screening form for potential clients should I choose to get into nutrition professionally someday. I'm not actually thinking so much in this direction right now so this exercise is purely theoretical in my case, but it's still required of me anyway.

The idea is to capture a broad overview of someone's physical statistics, personal habits and living circumstances with regard to how each might have an impact on their personal health as it currently stands. Basically, a set of initial questions that a nutritionist or similar might look to ask each of their clients in advance of their first face-to-face meeting.

It's not meant to be so detailed as to replace face-to-face meetings altogether, but not so limited that it results in the same first questions being asked of each client at the face-to-face meetings. This is what I've come up with so far, and I'd appreciate any general feedback anyone might have to offer. Is there anything obvious that I might be missing, and/or I asking too much in other areas? What do we reckon?

Note that I'm not asking anyone to reply with their actual answers to these questions, just for feedback on the set of questions themselves please.

Thanks in advance.

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Personal identity

1. Name
2. Gender
3. Date of birth
4. Ethnicity

5. Contact email
6. Contact phone number
7. Preferred method of contact

8. Occupation
9. Average hours worked per week

10. How many others do you live with?



Measurements and medical notes

11. Height (units)
12. Weight (units)
13. Waist circumference (units)

14. Any pre-existing medical conditions (if yes, what pre-existing medications, if any)?

15. Any family history of health issues?

16. Any allergies/intolerances/imbalances (if yes, what supplements do you take, if any)?

17. Most recent readings (include units, date taken and name of issuing GP):
Blood pressure:
Blood glucose:
HbA1c:
Triglycerides:
HDL cholesterol:
LDL cholesterol:



Lifestyle factors

18. How would you characterise your overall eating pattern e.g. standard Western, low fat, Mediterranean, low carb, ketogenic, vegetarian, vegan?

19. Provide a typical example of foods eaten across a given week (think of a food diary):

20. How often do you eat per day (include any regular snack times such as morning/afternoon tea, supper)?

21. How long do you typically go without eating in a day (e.g. overnight)?

22. Describe typical exercise routine(s) and duration across a given week?

23. Do you carry any physical injuries that may prevent/impair certain movements?

24. How many hours of sleep do you get per night, on average?

25. Do you drink alcohol (if yes, what type(s) and how much)?

26. Do you smoke (if yes, how many/day)?

27. Any history of particular diets or other health improvement initiatives, and if yes, what/when? Any history of weight loss/gain as a result, and if yes, how much?

Perhaps ask whether or not they're a parent, the child(ren)'s age(s), and if the kids have any issues that require special consideration?

There could also be a question regarding general financial situation: are you comfortable/below your means, or living paycheque-to-paycheque? Sub-question to this one - how often do you cook vs living off takeout?

Transportation and food availability: rural vs urban/suburban, do you own a vehicle?

Those are more specific, though, and not necessarily for an intake questionnaire, I suppose. I'm looking at this through the lens of questions I'd ask a new forum member if they were asking for help. I think you're correct in trying to avoid the intake interview being a rehashing of the questionaire, as if you couldn't have been bothered reading it. Something I appreciate about my doctor: I'm only there once a year, but she takes the time to at least glance at my chart so we're not wasting each other's time.

I'd say that's pretty comprehensive! But you may want to add one more question:

How much time do you spend on TikTok per day (estimate)?

But seriously it might be helpful to know (if the person works) what their workday consists of as far as movement or access to movement thru out the day. Some type of framework might be helpful in prescription.

Perhaps also ask if this potential client has access to basic kitchen tools and basic cooking skills - IMO, these, to some small degree, need to be developed if anyone wants a fighting chance to free themselves of processed fast food

How many times do you go the drive-thru to pick up food per week

Good luck and what you have is looking great Dr. Grav... hey, that has a certain ring too it ... hmmmm (insert thinking emoji )

Under occupation, ask about retired vs working
14, 15, 16, 23 you can add questions for further clarification such as "Please list"

Looks pretty comprehensive to me

No all of us get back reports from our GP on the results of blood work etc. I only get comments such as "Your potassium level is low" so I am not sure you will get complete answers to #17

How does your weekday diet differ from the weekend?

Personally I tend to do better on weekdays than weekends, where I see some people saying they actually do better at home than at work.

For alcohol--maybe more on pattern of drinking, is it a bit of wine with each dinner, or a whole bottle on Friday night, etc.

#21 needs some clarification. I know you're asking about the longest period BETWEEN patient putting food in mouth, but someone without knowledge of the benefits of fasting might think they should add up all the time when they're not actively putting food into their mouths.

Maybe ask instead, "In a typical 24 hour period, what is the longest stretch of time that you go without eating anything at all?"

And, under pre-existing medical conditions, you might also want to specifically ask if the client ever suffers from gas, bloating, or a noisy gut. Pre-low-carb, I had all those issues, but since I could still function and wasn't in any major pain, I considered a them to be NORMAL. Never once mentioned them to my doctors and would not have thought to list these as "pre-existing medical conditions!"

Thanks everyone for your feedback, it's all very helpful. For some reason I don't have the option to edit the original post, but I will incorporate several suggestions into my offline copy.


I think for this, I'll revise the question about how many people the patient lives with, to also include a count of how many of those people are dependents. That way it covers not just children, but people of any age with a disability requiring ongoing support.


These are things I think I'd prefer to ask in a face to face setting for the patient's sake. I can get possible clues as to whether or not this would be particularly useful on the basis of other information like their food history, plus the number of people in the household, plus the occupation and hours worked.


Perhaps if I captured a physical address instead. If they're in an inner city apartment, that might then lead me to ask different questions around transportation and exercise than say, somewhere rural.

While undoubtedly useful, I think these are all things that I'd probably save for a face-to-face meeting, depending on the answers to other questions like their occupation, their food history and so on.


Haha, no way do I ever see that happening. The prospect of possibly just becoming an author someday is more than enough for me.

Excellent point. To answer yes to those questions would only lead to the obvious follow-up question of "what are these things," so I don't think it's too much extra to add that here. The implication of each such issue in the wider context of other information they provide can form face-to-face discussion points for later.


That's fine, I imagine there will be some people who might never have been tested for any of these things at all. One can only work with whatever information the patient chooses to provide.

Not a bad idea, I can flesh out the food diary question a bit, with instructions to note regular variations across the week e.g. weekdays vs weekends.


I think I might save that one for the face-to-face. Some people (like me for example) don't drink at all, so the extent to which drinking habits might need fleshing out could potentially vary quite a bit from person to person. People at the other end might not be entirely forthcoming with their answer to this question on paper either.

Yes, that's a great idea. I will update the wording on that question accordingly.


Fair point, although I'd rather not get too specific at the form stage. I'm thinking medical conditions and/or issues of general discomfort? That could include not just gut issues but also things like migraines for example.

Continue the good works Grav!

Re pre-existing medical conditions, you might do like many doctors now do on their intake forms. They provide a list of medical conditions so the patient can just check off the ones they suffer from. Then they have a line where they ask if there are any other medical conditions the patient has which are not included on the list.

Typically things like diarrhea, constipation and irregularity are included on the list but I've never seen gas/bloating/abdominal discomfort/noisy gut. Since never listed as potential medical conditions, I suspect most people out there consider these to be just "normal conditions" and only a problem if they become bad enough to interfere with social life or work.

Grav, please keep us posted. I think we are now all invested in your work.

Good luck

If u r still taking suggestions.....

occupation. Parenting.. stay at home mother. Housekeeper, part time work.....run a small farm. What is the purpose of this question.....somehow this question is aimed at a person who works full time at one job. That is men historically. Most women have two -three jobs. So.... again, what is the goal of this question..... what info is this question trying to get at ?

It is a question that always stumps me.

Also , maybe a two day record of a typical day....

where a person sleeps. Ive met a number of oeople that must sleep sitting up in a chair.... maybe that is better in face to face.