Nutrition Intake Form
The Nutrition Intake Form is a simple way for you to keep track of what you eat and drink each day. This form can be used to help you make healthier choices, and to monitor your progress over time.
3 minutes to complete
Eligibility
Children under the age of five years, people who are pregnant and lactating, people with tuberculosis, and people suffering from acute malnutrition are eligible to fill the nutrition intake form.
Questions for Nutrition Intake Form
Questions
1.
What is your name?
The answer should be a text input.
2.
Age
The answer should be a single choice:
- Under 18
- 18-24 years old
- 25-34 years old
- 35-44 years old
- 45-54 years old
- Over 55
3.
Gender
The answer should be a single choice:
- Male
- Female
- Other
- Prefer not to say
4.
Phone Number
The answer should be a phone number.
5.
Nationality
The answer should be a country.
6.
What is your weight?
The answer should be a text input.
7.
What is your height?
The answer should be a text input.
8.
How many meals do you eat per day?
The answer should be a text input.
9.
What types of food do you typically eat for each meal?
The answer should be a text input.
10.
Do you eat any snacks during the day?
The answer should be a text input.
11.
Do you drink any beverages other than water?
The answer should be a text input.
12.
What is your overall intake of calories per day?
The answer should be a text input.
13.
What is your overall intake of protein per day?
The answer should be a text input.
14.
What is your overall intake of fat per day?
The answer should be a text input.
15.
What is your daily water intake in ounces?
The answer should be a text input.
16.
Do you have any allergies?
The answer should be a text input.
17.
Do you have any medical conditions?
The answer should be a text input.
Forms Similar to Nutrition Intake Form
- Daily Nutrition Intake Form
- Child Nutrition Intake Form
- Adult Nutrition Intake Form
- Pregnancy Nutrition Intake Form
Here are some FAQs and additional information
on Nutrition Intake Form
What is the purpose of the Nutrition Intake Form?
The purpose of the Nutrition Intake Form is to provide information about an individual's dietary intake and to identify any potential nutritional deficiencies.
Who should complete the Nutrition Intake Form?
The Nutrition Intake Form should be completed by anyone who is interested in receiving information about their dietary intake and identifying any potential nutritional deficiencies.
How much nutrition is needed daily?
According to research, women are likely to need between 1,600 and 2,400 calories a day, and men from 2,000 to 3,000. However, this depends on their age, size, height, lifestyle, overall health, and activity level.
Why is nutrient intake important?
A healthy diet throughout life promotes healthy pregnancy outcomes, supports normal growth, development, and aging, helps to maintain healthy body weight, and reduces the risk of chronic disease leading to overall health and well-being.
Want to use this template?
Loved by people at home
and at work
“BlockSurvey is a simple, effective, and scalable tool for creating surveys for leadership and learning assessment. It's one of this year's best buying choices. Each month, it keeps improving and strives to serve its customers needs.”
Nelson Emilio
Personal Branding Strategist
“I use BlockSurvey to get feedback about all my activities and events. It is really easy to get started and create my first surveys! Then I could see how easy it was to share them. Now I am thinking to use BlockSurvey also within my creative process as an author in order to listen and engage with my audience, knowing that anonymity provides the most sincere and reliable answers.”
Georgina García-Mauriño
Author & Designer
What's next? Try out templates like
Nutrition Intake Form
1000+ Templates, 50+ Categories
Want to create secure online forms and surveys?
Join BlockSurvey.
Welcome to BlockSurvey
Finally, build secure surveys. It only takes seconds to sign up.