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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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Name
*
First
Last
Cell Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Referred By
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
*
Married
Single
Divorced
Widowed
Number of Children
*
Please enter a number from
0
to
20
.
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?
less than 30 minutes
30 - 60 minutes
60 - 90 minutes
90 - 120 minutes
over 120 minutes
On a scale of 0-10 how intense is your exercise?
*
0
1
2
3
4
5
6
7
8
9
10
0 being barely increasing your heart rate, 10 being giving it everything you have
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
AM
PM
Do you sleep well?
*
Yes
No
Sometimes
Do you wake up during the night?
*
Yes
No
What time do you wake up during the night?
*
:
HH
MM
AM
PM
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
AM
PM
How do you typically feel when you wake up in the morning?
*
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.
Are you currently taking any vitamins, minerals, herbs, homeopathic remedies, prescription or non-prescription medications, aspirin, laxatives, diet pills, or any other supplements?
*
Yes
No
Please list below including dosages/amounts.
*
Do you have any know allergies/reactions to any medications, supplements, or herbs?
*
Yes
No
Please list allergies/reactions.
*
Are you currently under a doctor’s/practitioner’s care for a specific issue?
*
Yes
No
What is your doctor’s/practitioner’s name and what treatments are you undergoing?
*
Have you ever been diagnosed with a medical condition?
*
Yes
No
Please explain the diagnosis.
*
Have you ever been seriously injured, hospitalized, or suffered from a disease?
*
Yes
No
Please explain.
*
How would you describe your energy level throughout the day?
*
On a scale of 0-10 what is your stress level?
*
0
1
2
3
4
5
6
7
8
9
10
0 being low, 10 being high
Do you feel your libido is adequate?
*
Yes
No
Have you lost interest in activities you used to enjoy?
*
Yes
No
What do you do to relax and unwind?
*
Do you smoke?
*
Yes
No
How many cigarettes per day?
*
Please enter a number from
0
to
50
.
Are you regularly exposed to secondhand smoke?
*
Yes
No
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?
*
Yes
No
Explain your exposure to toxic substances.
*
Comments
This field is for validation purposes and should be left unchanged.
Jen
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Get Evaluated Now
Client Portal
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Text Me for Support
(949) 636-1390