Free Evaluation | Jen Fisher Fit

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

Name*
First Last
Cell Phone*
Address*
Street Address Address Line 2 City State ZIP Code
Referred By

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Date of Birth*
Date Format: MM slash DD slash YYYY
Height (Feet)*
Please enter a number from 3 to 8.
Height (Inches)*
Please enter a number from 0 to 11.99.
Weight (Pounds)*
Please enter a number from 50 to 700.
Occupation*
Average Hours Worker Per Week*
Please enter a number from 0 to 168.
Relationship Status*
Number of Children*
Please enter a number from 0 to 20.

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What are Your Top 3 - 5 Health Concerns?
Health Concern 1*
Health Concern 2*
Health Concern 3*
Health Concern 4
Health Concern 5
What would you like to gain from a health and nutrition program? What are your personal goals?
How would you best describe your daily activities?*
- Sedentary – spend most of the day sitting (i.e. desk job)
- Moderately active – spend at least half of the day on your feet (i.e. teacher)
- Active – spend at least half of the day doing physical activity (i.e. flight attendant)
- Very Active – spend at least half the day doing heavy physical activity (i.e. construction)
On average, how many hours per day are you sitting (at work, TV, etc)?*
Please enter a number from 0 to 24.
What types of hobbies and activities do you enjoy?*
How many days per week do you exercise?*
Please enter a number from 0 to 7.
What type(s) of exercise do you engage in?*
Examples: resistance training, strength training, cardiovascular, high-intensity interval, yoga, etc
For how long do you typically exercise?
On a scale of 0-10 how intense is your exercise?*
0 being barely increasing your heart rate, 10 being giving it everything you have

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On average, how many hours do you sleep each night?*
Please enter a number from 0 to 24.
What time do you usually go to bed?*

: HH

MM
Do you sleep well?*
Do you wake up during the night?*
What time do you wake up during the night?*

: HH

MM
Do you know why you wake up during the night?*
Examples: to urinate, your mind is racing, etc.?
What time do you usually wake up in the morning?*

: HH

MM
How do you typically feel when you wake up in the morning?*

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How much PURE water do you drink per day in ounces?*
Please enter a number from 0 to 400.
Don’t include beverages containing water like juice or tea
How often do you drink alcohol?*
Examples: never, daily, twice per week, etc.
How many alcoholic drinks per month?*
Please enter a number from 0 to 500.
What else do you drink on a regular basis?
- Coffee
- Tea
- Soda
- Juice
- Energy Drinks
- Other
If "other" please describe.
What % of your food is cooked/prepared at home?*
Please enter a number from 0 to 100.
What does a typical breakfast look like for you?*
What kinds of fats do you cook with?*
Examples: Butter, olive oil, canola oil, “I don’t know”, etc.
In your opinion, what are the three least healthy foods you eat each week and why?*
What is your favorite food?*
What is your least favorite food?*
What do you crave?*
Examples: Sugar, salt, bread, coffee, etc.
List any protein powders or protein bars you eat, if any.
List any known food allergies and/or sensitivities.

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Are you currently taking any vitamins, minerals, herbs, homeopathic remedies, prescription or non-prescription medications, aspirin, laxatives, diet pills, or any other supplements?*
Please list below including dosages/amounts.*
Do you have any know allergies/reactions to any medications, supplements, or herbs?*
Please list allergies/reactions.*

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Are you currently under a doctor’s/practitioner’s care for a specific issue?*
What is your doctor’s/practitioner’s name and what treatments are you undergoing?*
Have you ever been diagnosed with a medical condition?*
Please explain the diagnosis.*
Have you ever been seriously injured, hospitalized, or suffered from a disease?*
Please explain.*

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How would you describe your energy level throughout the day?*
On a scale of 0-10 what is your stress level?*
0 being low, 10 being high
Do you feel your libido is adequate?*
Have you lost interest in activities you used to enjoy?*
What do you do to relax and unwind?*

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Do you smoke?*
How many cigarettes per day?*
Please enter a number from 0 to 50.
Are you regularly exposed to secondhand smoke?*
How many days per week are you exposed to secondhand smoke?*
Please enter a number from 0 to 7.
Have you been exposed to toxic substances at work or home?*
Explain your exposure to toxic substances.*
Phone
This field is for validation purposes and should be left unchanged.

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Health & Nutrition Assessment Questionnaire

Step 1 of 9 - Contact Information

What are Your Top 3 - 5 Health Concerns?