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Nutrition consent form

This is a nutrition consent form that can be used by nutrition clients. It includes information about nutrition counseling.

2 minutes to complete

Eligibility

The consent form must be filled out by the parent/guardian of a child who wishes to enroll in the Nutrition program. If the child is 18 years or older, he/she must be the one to fill the form.

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Questions for Nutrition consent form

Questions

1.

How do you prefer to receive information about nutrition? (i.e. pamphlets, online, etc.)

The answer should be a text input.
2.

What are your preferred methods of communication? (i.e. phone, email, text)

The answer should be a text input.
3.

How often would you like to receive updates on your progress?

The answer should be a single choice:
  1. Not often
  2. Often
  3. Very often
4.

What is your current nutritional knowledge?

The answer should be a single choice:
  1. No knowledge
  2. Reasonable knowledge
  3. Good knowledge
5.

What are your current eating habits?

The answer should be a text input.
6.

What are your current physical activity levels?

The answer should be a single choice:
  1. No physical activity
  2. Reasonable physical activity
  3. Good physical activity
7.

What are your current weight and height?

The answer should be a text input.
8.

What are your current health goals?

The answer should be a text input.
9.

What are your current medical conditions?

The answer should be a text input.
10.

Are you pregnant or breastfeeding?

The answer should be a single choice:
  1. Yes
  2. No
11.

Do you have any food allergies or sensitivities?

The answer should be a single choice:
  1. Yes
  2. No
12.

Do you have any religious or cultural dietary restrictions?

The answer should be a single choice:
  1. Yes
  2. No
13.

Do you have any other concerns or questions?

The answer should be a single choice:
  1. Yes
  2. No
14.

Do you give your consent to sign up for this nutrition program?

The answer should be a single choice:
  1. Yes
  2. No

Forms Similar to Nutrition consent form

  • Patient nutrition consent form
  • Nutrition education consent form
  • Nutrition research consent form
  • Parental consent form for nutrition education
  • Nutrition program consent form

Here are some FAQs and additional information
on Nutrition consent form

What is a nutrition consent form?

A nutrition consent form is a document that gives permission for a person to receive nutrition education or counseling from a registered dietitian or nutritionist.

Why is a nutrition consent form necessary?

A nutrition consent form is necessary in order to ensure that the person receiving nutrition education or counseling is aware of the potential risks and benefits associated with the service. It also helps to protect the dietitian or nutritionist from liability in the event that something goes wrong.

What information is typically included in a nutrition consent form?

A nutrition consent form typically includes information about the risks and benefits of the nutrition education or counseling service, as well as the dietitian or nutritionist's qualifications. It may also include a statement of consent from the person receiving the service.

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