First Name *

Last Name *

Email *

Mobile *

Gender

Year of Birth *

Height (cm)

Current weight (kg)

Goal weight (kg)

Highest adult weight (kg)

Weight change in last 6–12 months

Is this your first time eating keto?

Women’s Health (if applicable)

Do you regularly experience any digestive issues?

Alcohol intake

Physical activity (type and frequency)

Current stress level

Average sleep per night

Approximate daily fluid intake

History of any of the following (select all that apply):

Have you ever been advised to restrict salt intake?

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For personal progress tracking only.

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Thank you for completing your intake form.

This information helps us tailor your nutrition plan to your individual health needs.

We look forward to supporting you on your health journey.

Thank you for completing your intake form.

This information helps us tailor your nutrition plan to your individual health needs.

We look forward to supporting you on your health journey.

Dietitian Intake Form