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Health & Nutrition Assessment Questionnaire

To ensure the maximum benefit of Nutritional Therapy, it is important that your information is accurate and up-to-date. If you notice any changes to your health, begin taking new prescriptions, etc., please notify me as soon as possible. It is also your right as a client to access, update, or delete your records at any time. Though Nutritional Therapy Practitioners (NTPs) like myself are not HIPAA regulated entities, I am committed to protecting client privacy and uphold the privacy best practices and the policies laid out in the U.S. Standards for Privacy of Individually Identifiable Health Information. Please see the Disclaimer for further details.

Note: If any of the required fields are not applicable, simply type “N/A”.

Jen Fisher, NTP
[email protected]
(949) 636-1390

Step 1 of 9 - Contact Information

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  • Date Format: MM slash DD slash YYYY
  • Please enter a number from 3 to 8.
  • Please enter a number from 0 to 11.99.
  • Please enter a number from 50 to 700.
  • Please enter a number from 0 to 168.
  • Please enter a number from 0 to 20.
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  • What are Your Top 3 - 5 Health Concerns?

  • Please enter a number from 0 to 24.
  • Please enter a number from 0 to 7.
  • Examples: resistance training, strength training, cardiovascular, high-intensity interval, yoga, etc
  • 0 being barely increasing your heart rate, 10 being giving it everything you have
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  • Please enter a number from 0 to 24.
  • :
  • :
  • Examples: to urinate, your mind is racing, etc.?
  • :
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  • Please enter a number from 0 to 400.
    Don’t include beverages containing water like juice or tea
  • Examples: never, daily, twice per week, etc.
  • Please enter a number from 0 to 500.
  • Please enter a number from 0 to 100.
  • Examples: Butter, olive oil, canola oil, “I don’t know”, etc.
  • Examples: Sugar, salt, bread, coffee, etc.
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  • 0 being low, 10 being high
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  • Please enter a number from 0 to 50.
  • Please enter a number from 0 to 7.
  • This field is for validation purposes and should be left unchanged.
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  • Jen
  • Friends
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  • Get Evaluated Now
  • Client Portal
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  • Text Me for Support (949) 636-1390