Download Sports Performance Nutrition Questionnaire

Sports Performance Nutrition Questionnaire
Please print legibly, answer all questions, and return completed questionnaire to Performance Unleashed Staff.
Youth Athlete Name: ________________________________________________________________________________
Parent/Guardian Name: ____________________________________________________________________________
Primary Contact Phone: ________________________Primary Email: ___________________________________
Mailing Address: _____________________________________________________________________________________
Energy
How would you describe your athlete’s eating habits? ___ Good ___Fair ___Poor
How many times a day does your athlete eat? ___ Times Per Day
Does your athlete have days of rest? __Yes __No If so, how frequently? ______________
Rate your athlete’s average activity level (1=low, 3=moderate, 5=intense, 5+=off the charts):
1
2
3
4
5
5+
If your athlete has “intense” and/or “off the chart” days, please describe:
_________________________________________________________________________
Recovery
Rate how you and your athlete feel that your athlete’s body handles the sports activity load
(1=struggles, 3=ok/could improve, 5=good, 5+=very well/bounces right back):
1
2
3
4
5
5+
Does your athlete experience any of the following? (check all that apply)
__Joint Pain __Periods of Exhaustion or “Crash” __Seasonal Allergies __Asthma
__Recurring Colds __Difficulty Focusing __Any Medical Condition Not Mentioned
If you checked anything, please describe (i.e., frequency, duration, etc.): _______________
_________________________________________________________________________
Describe any relevant past/current injury & effect on your athlete’s sports performance:
_________________________________________________________________________
Growth
Current Age & DOB: _________________ Height: ______________ Weight: __________
Has your athlete experienced any recent growth spurts? __Yes __No If so, please describe:
_________________________________________________________________________
Are their concerns about your athlete’s current weight/build? __Yes __No
If so, please describe: ______________________________________________________
If your athlete is trying to increase weight/muscle mass, please describe current strategy:
_________________________________________________________________________
_________________________________________________________________________
If your athlete is trying to decrease weight, please describe current strategy:
_________________________________________________________________________
_________________________________________________________________________
Diet & Hydration
Please describe your athlete’s average daily diet: _________________________________
_________________________________________________________________________
_________________________________________________________________________
Specifically, what does your athlete typically eat for breakfast?
_________________________________________________________________________
What types of foods does your athlete snack on in between classes, practices, games, etc.?
_________________________________________________________________________
Does your athlete ever go long periods w/out eating? __Yes __No If so, when/why?
_________________________________________________________________________
Average Daily Caloric Intake (if known): _________________________________________
Is your athlete following a specific diet program? __Yes __No If so, please describe:
_________________________________________________________________________
How many 8 oz. cups of fluid does your athlete normally consume per day? ___cups/day
In a typical workout session, how many cups of water, sports drink, juice, or other
beverages does your athlete drink before and/or during exercise? (check one)
__None __1-2 Cups __3-5 Cups __More than 5 Cups
Does your athlete currently take any vitamins or dietary supplements? __Yes __No
If so, which ones? (check all that apply & list brand, dose, frequency of use, etc.)
__ Protein Shakes/Powders __Creatine __ Vitamins __ Minerals __ Amino Acids
__ Sports/Energy Drinks __Sports Bars __Amino Acids __HMB __Glutamine __Herbs
__ Glucosamine/Chondroitin __ Ephedra/Fat Burners __NO2 __Other, Specify __________
_________________________________________________________________________
_________________________________________________________________________
Is your athlete taking any medications? __Yes __No If so, please list & state reason:
_________________________________________________________________________
Do you or your athlete have any concerns/issues relative to diet & sports performance that
have not been covered in this questionnaire? __Yes __No If so, please describe:
_________________________________________________________________________
_________________________________________________________________________
Rate from 1-5 how important you and your athlete feel nutrition is to sports performance:
1
2
3
4
5
5+
Are you interested in learning more about nutritional supplements that are customized to
meet the needs of your athlete based on the information provided? __Yes __No
If so, what is the best way to reach you? __ Phone __Email __Mail