Nutrition clinical record template (with every field explained)

A nutrition clinical record is not a form: it is the basis on which you will justify every decision for months. This template covers the blocks that should always be there, with an explanation of what each field is for and which ones you can trim without losing clinical judgement.

The most common mistake when building your own clinical record is asking for too much at the first visit. A sixty-field form drags out the intake, tires the client, and produces data you will never use. The goal is not to collect everything collectable: it is to collect what would change a decision.

Block 1 · Identification and admin

The minimum needed to identify and contact the client, plus consent. It is the only block with direct legal implications, so it is worth closing properly from day one.

• Full name and identity document.
• Date of birth (not age: age calculates itself and goes stale).
• Phone and email, plus preferred channel.
• Date of first consultation and acquisition channel (useful later for knowing what actually brings you clients).
• Signed informed consent and the date it was signed.
• Separate consent for photographs, if you take them.

Block 2 · Reason for consultation and goals

This is where the success of the treatment gets defined. Record the reason in the client’s own words, not translated into jargon: the difference between "I want to lose weight" and "I want my knee to stop hurting on stairs" changes the entire approach.

• Reason for consultation, verbatim.
• Client’s goal, stated measurably and with a timeframe.
• Your clinical goal, which may not match the one above.
• Expectations about the pace of change: the single best place to prevent conflict.
• Previous attempts: what they tried, how long it lasted, and why they stopped.

Block 3 · Clinical history

• Diagnosed conditions, with an approximate date of diagnosis.
• Current medication, dose, and since when (relevant for interactions and for effects on appetite or weight).
• Current supplementation, including what the client does not consider "medication".
• Allergies and intolerances, separating diagnosed from self-reported.
• Relevant surgeries, especially digestive.
• First-degree family history with metabolic or cardiovascular impact.
• Recent lab work available, and its date.

Block 4 · Anthropometry and body composition

Record the value and the method. A skinfold taken with a different caliper, or bioimpedance under different conditions, is not comparable — and without the method noted there is no way to know that three months later.

Block 5 · Habits and lifestyle

• 24-hour recall or a 3-day record, depending on the time you have.
• Usual meal structure: how many, when, and where they happen.
• Who shops and who cooks at home — this determines how much real control the client has.
• Budget and food access, asked without judgement.
• Physical activity: type, frequency, duration, perceived intensity.
• Occupation and work shifts.
• Sleep: hours and perceived quality.
• Alcohol and tobacco use.
• Perceived stress and how it relates to intake.

The question about who cooks is almost always skipped, and it explains a huge share of poor adherence. A perfect plan handed to someone who does not decide their household menu will not be followed.

Block 6 · Assessment and nutritional diagnosis

• Estimated energy requirement and the formula used.
• Proposed macronutrient distribution and the reasoning behind it.
• Nutritional diagnosis in one sentence.
• Identified risks and red flags for referral.

Block 7 · Plan and instructions

• Plan delivered, with version and date.
• Specific agreed instructions — few in number and verifiable.
• Goals for the next visit.
• Agreed review date.

Block 8 · Progress

Every follow-up should add an entry, never overwrite the previous one. At minimum: date, that day’s anthropometry, observed adherence, changes in medication or context, plan adjustments, and the reason for the adjustment. That "reason" is what turns the record into a clinical document rather than a list of weights.

Adapting the template to your practice

1. Start with blocks 1, 2, 4, and 7: the minimum viable set for working with judgement.
2. Add block 3 in full if you see clinical cases or clients on multiple medications.
3. Halve block 5 if your first visit runs under 45 minutes, and finish it at the second.
4. Turn into closed fields anything you will later want to filter; leave as free text anything you will only read.
5. Review the template every six months and delete fields you have never looked at.

One last note on format: it does not matter whether you start on paper or digital, but decide early. Rebuilding two years of paper records to move them into a tool is a job nobody finishes.