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

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