On Your Mark Nutrition

Athletes: Medical Health History & Nutritional Questionnaire

Medical Health History

&

Nutritional Questionnaire

Athletes

Name *
Name
Birthday *
Birthday
Why do you want to see a Dietitian? (check all that apply) *
SPORT
(e.g., off season, pre-season, in-season, taper week(s), etc.)
(e.g., Monday-Sunday; duration; intensity; training goal for the day, etc.)
What is missing from your team's provision of nutritional care that you would like to receive from OYMN? *
HISTORY
Examples of Body Composition Tools include: DEXA Scan, Skin Calipers, InBody (BIA), BODPOD, Ultrasound
INTAKE
1 drink = 1.5 oz 80-proof liquor; 5 oz wine; 12 oz beer
How would you describe your recent eating/behavior patterns (last 3 months)? (check all that apply) *
LIFESTYLE
Please indicate if you: *
_____ hrs (weekday) ____ hrs (weekend)
COMMITMENT
0 = not committed at all; 1 = 25% committed 2 = 50% committed 3 = 75% committed 4 = 90% committed 5 = 100% committed
OTHER
Are there any other tests you are interested in adding on? *
Please select from below any tests you are interested in completing that you are not already completing in your package. Please feel free to email Katie for more information about each of the tests.
What methods of communication do you prefer while working with Katie? *
Check all that apply.
Are you interested in learning more about nutrition during this program or not at all? *
FEMALES ONLY
FOR ALL INDIVIDUALS
The above answers have been answered correctly and truthfully to the best of my knowledge. *