Nutrition Intake Form Template for New Zealand

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Key Requirements PROMPT example:

Nutrition Intake Form

"I need a comprehensive Nutrition Intake Form for my new private nutrition practice opening in Auckland in March 2025, compliant with New Zealand healthcare regulations and suitable for both in-person and telehealth consultations."

Document background

The Nutrition Intake Form serves as a fundamental tool for healthcare providers in New Zealand to collect comprehensive client information necessary for nutritional assessment and care planning. This document is designed to comply with New Zealand healthcare regulations, including the Privacy Act 2020 and Health Information Privacy Code 2020, while gathering essential information about a client's health status, dietary habits, medical history, and nutritional goals. The form is typically used during initial consultations with nutrition professionals and may be updated periodically to reflect changes in the client's health status or dietary needs. It includes sections for personal information, medical history, dietary preferences, and lifestyle factors, facilitating a thorough understanding of the client's nutritional needs and enabling the development of appropriate dietary recommendations.

Suggested Sections

1. Personal Information: Basic client details including name, date of birth, contact information, and preferred contact method

2. Current Health Status: Current health conditions, medications, supplements, and recent medical procedures

3. Dietary History: Current eating patterns, meal timing, food preferences, and typical daily food intake

4. Lifestyle Factors: Physical activity, sleep patterns, stress levels, and occupation-related factors affecting nutrition

5. Goals and Concerns: Client's nutritional and health goals, specific concerns, and expected outcomes

6. Food Habits: Eating behaviors, food allergies/intolerances, dietary restrictions, and cultural considerations

7. Medical History: Family medical history, previous health conditions, and historical weight changes

8. Consent and Privacy: Privacy policy acknowledgment and consent for information collection and sharing

Optional Sections

1. Sports Nutrition: Additional section for athletes or highly active individuals, including training schedules and performance goals

2. Pregnancy/Lactation: Specific section for pregnant or nursing individuals, including relevant health information and nutritional needs

3. Pediatric Information: Modified sections for children, including growth history and developmental considerations

4. Eating Disorder History: Specialized section for clients with past or present eating disorders

5. Weight Management History: Detailed section for clients specifically seeking weight management support

Suggested Schedules

1. Food Diary Template: Template for recording 3-7 days of detailed food intake

2. Measurement Record: Form for tracking anthropometric measurements

3. Symptom Diary: Template for recording food-related symptoms or reactions

4. Privacy Policy: Detailed privacy policy and information handling procedures

5. Medical Release Form: Authorization form for communicating with other healthcare providers

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Wellness and Fitness

Sports and Athletics

Education

Aged Care

Corporate Health

Public Health

Medical Research

Private Practice

Relevant Teams

Clinical Services

Nutrition Services

Healthcare Administration

Quality Assurance

Compliance

Medical Records

Research and Development

Public Health

Sports Medicine

Primary Care

Relevant Roles

Registered Dietitian

Clinical Nutritionist

Sports Nutritionist

Healthcare Administrator

Medical Practice Manager

Research Nutritionist

Public Health Nutritionist

Nutrition Consultant

Clinical Director

Sports Medicine Physician

General Practitioner

Health Information Manager

Compliance Officer

Quality Assurance Manager

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Simple Intake Form

A New Zealand-compliant intake form for collecting and managing client information, structured according to NZ privacy laws and business requirements.

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Authors

Alex Denne

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