Nutrition Initial Intakes Form

for Food Allergies

Name:________________________________

Date of Birth:________________________________

Phone Number:________________________________

Email Address: ________________________________

City:________________________________

State:________________________________

Zip:________________________________

Do you have any diagnosed food allergies?

• Yes ☐ No ☐

If yes, please list:

1. ________________________________

2. ________________________________

3. ________________________________

Have you experienced any allergic reactions in the past?

• Yes ☐ No ☐

If yes, please describe the reaction(s):

________________________________________________________________

Typical Daily Meal Schedule:

Breakfast:________________________________

Lunch:________________________________

Dinner:________________________________

Snacks: ________________________________

Do you follow a special diet (e.g., vegetarian, vegan, gluten-free)?

• Yes ☐ No ☐

If yes, please specify: ________________________________________________________________

List any food items you enjoy:

· ________________________________

· ________________________________

· ________________________________

List any food items you dislike or refuse to eat:

· ________________________________

· ________________________________

· ________________________________

Do you have allergies to any of the following?

• ☐ Milk

• ☐ Eggs

• ☐ Peanuts

• ☐ Tree nuts

• ☐ Fish

• ☐ Shellfish

• ☐ Soy

• ☐ Wheat

☐ Other (Please specify): ________________________________________________________________

Please provide any other relevant information regarding your food allergies or nutritional needs:

________________________________________________________________

________________________________________________________________

__________________________ __________________________

Signature Date

Please fill out this form to the best of your ability. It will help us better understand your nutritional needs and manage any food allergies effectively.