Sports Nutrition Assessment Form

Gazelle Nutrition Lab / For Clients / Sports Nutrition Assessment Form

Name*
Birth Date
MM slash DD slash YYYY
Age
Date
MM slash DD slash YYYY
Please fill out the following information to the best of your knowledge. Certain items may not apply to you (e.g. coach name and address). If they do not, please leave those sections blank.
Medical Information
Physician or medical provider:
Name Address Phone
Other Health Care Providers
(E.g. physiotherapist, chiropractor, naturopath, athletic therapist, massage therapist):
Current medications:
Medical history:
Laboratory values:
If you have had blood work done recently this is great. Please provide any numbers you have for the indices in the table below.
Date blood work was taken:
MM slash DD slash YYYY
CMP (Comprehensive Metabolic Panel)
CBC (Complete Blood Count)
Other
Na (Sodium)
WBC (White Blood Cell Count)
Mg (Magnesium)
K (Potassium)
RBC (Red Blood Cell Count)
Zn (Zinc)
Cl (Chloride)
Hct (Hematocrit)
Vit D (Vitamin D)
BUN (Blood Urea Nitrogen)
HgB (Hemoglobin)
B12 (Vitamin B12)
Cr (Creatinine)
MCV (Mean Cell Volume)
Folate
Alb (Albumin)
MCH (Mean Corpuscular Hemoglobin)
Ferritin
Glc (Glucose)
MCHC (Mean Corpuscular Hemoglobin Concentration)
Fe (Iron)
CO2 (Carbon Dioxide)
TIBC (Total Iron Binding Capacity)
Ca (Calcium)
Saturation
ALP (Alkaline Phosphatase)
TSH (Thyroid Stimulating Hormone)
AST (Aspartate Aminotransferase)
Estradiol
ALT (Alanine Aminotransferase)
Estrone
Alb:Cr (Albumin to Creatinine Ratio)
Additional comments
Physical Status
Height:
Current Weight:
Competition weight (if applicable):
Usual Adult Body Weight:
Highest body weight
at age
Lowest body weight
at age
Body composition:
If you have had your body fat and muscle mass estimated by devices such as skinfold calipers, the Bod Pod, or bioimpedance analysis please provide the information below.
Lean Body Mass:
%
Body Fat:
%
Date measured:
MM slash DD slash YYYY
Lifestyle/ Sports Information
In which sports do you participate (list sports and how often you do each sport):
Coach
Coach Name:
Coach Address:
Coach Phone:
Injuries:
List from newest to oldest
Type of Injury: Date Injured: Therapy? (E.g physio): Time to heal/ongoing:
Current training period:
- Training
- Competition
- Recovery
Comments
Typical current training schedule:
List activity in each day of the week below.
Mon Tue Wed Thur Fri Sat Sun
Diet
Vitamin and mineral supplements:
Weight loss, herbal or sports supplements:
Food allergies:
Food dislikes:
Describe your daily eating habits:
Alcohol Frequency:
Alcohol Quantity:
Alcohol Type:
What do you eat and drink (list specific foods/drinks and quantities):
2-3 hours before workout?: 1 hour before workout?: During a workout?: After a workout?:
How often do you eat at restaurants or consume take-out or fast food?
How often do you eat snack foods? Type?
Describe your typical eating environment (e.g. alone, with a spouse or roommate, in car, at desk):
What is your primary goal for your nutrition counselling experience overall?
What 3 nutrition changes do you think should you make starting today?
1. 2. 3.
Preferred strategy for nutrition intervention:
- Day-to-day meal plan
- Food choices (e.g. 2 starches, 3 protein) + selections
- General guidelines (e.g. eat 6 vegetable servings/day)
Other comments:
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Email
This field is for validation purposes and should be left unchanged.

Sports Nutrition Assessment Form

Medical Information

Laboratory values:

Physical Status

Body composition:

Lifestyle/ Sports Information

Coach

Diet

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Type of Injury:	Date Injured:	Therapy? (E.g physio):	Time to heal/ongoing:

Mon	Tue	Wed	Thur	Fri	Sat	Sun

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Sports Nutrition Assessment Form

Medical Information

Laboratory values:

Physical Status

Body composition:

Lifestyle/ Sports Information

Coach

Diet

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