Print out the following page, complete the questionnaire, and mail to:
Fern's Nutrition
16932 Gothard, Suite H
Huntington Beach, CA 92647

NAME ______________________________________ DATE_________

Phone__________________ Email:_____________________________

AGE ________________

HEIGHT _____________

WEIGHT _____________

DIET

How many servings of fruits and vegetables do you consume each day?
(Circle One)

One or Fewer Two to Four Five or More

How many servings of red meat, fried food, or dairy products do you consume daily? (Circle One)

One or Fewer Two to Four Five or More

LIFESTYLE

In a typical week how many days do you exercise? (Circle One)

One or Fewer Two to Four Five or More

How would you rate your stress level on a scale of one to ten? (ten being high stress) (Circle One)

1-3 4-7 8-10
(Low Stress) (Moderate Stress) (High Stress)

Do you smoke? (Circle One) Yes No

How often each week do you consume alcohol? (Circle One)

Never/Seldom Sometimes Often

Rate your overall energy level with 10 being high or optimal energy. (Circle One)

1-3 4-7 8-10
(Low Energy) (Moderate Energy) (High Energy)

Do you have problems with memory or concentration? (Circle One) Yes No

Do you experience indigestion during or after eating? (Circle One) Yes No

Do you have gas or bloating following meals? (Circle One) Yes No

Do you experience heartburn during or after eating? (Circle One) Yes No

IMMUNITY

How many colds do you have each year? (Circle One)

None One or Two Three or More

Do your colds or flu last more that 5 days? (Circle One) Yes No

Do you experience frequent infections? (Circle One) Yes No

MEN ONLY

Do you urinate more than once in the night? (Circle One) Yes No

Do you feel like you do not completely empty your bladder during urination?
(Circle One) Yes No

Is urination ever accompanied by pain, burning, or difficulty in starting or
stopping urination? (Circle One) Yes No

WOMEN ONLY

For Pre-Menopausal Women:
How would you evaluate your premenstrual syndrome symptoms (PMS)? (Mood
swings, cramps, water retention, insomnia, fatigue) (Circle One)

Light Moderate Severe

For Menopausal Women:
How would you evaluate your menopausal symptoms? (Hot flashes, nervousness,
sleep disturbances, forgetfulness) (Circle One)

Light Moderate Severe

Do you have a personal health history which includes any of the following?
(Check those that apply)

Elevated Cholesterol _____ Eye Problems ____
High Blood Pressure _____ Thyroid Problems ____
Arthritis _____ Low Blood Sugar or Diabetes ____
Osteoporosis _____ Other _______________________
_______________________
_______________________

What are your Three Primary Health Goals for the next 6-12 months?

1.) __________________________________________________________

______________________________________________________________

______________________________________________________________

2.) __________________________________________________________

______________________________________________________________

______________________________________________________________

3.) ______________________________________________________________

______________________________________________________________

______________________________________________________________