Individual Consultation Intake Form Name * First Name Last Name Phone * (###) ### #### Email * Preferred method of contact * e-mail phone Sex * Female Male Age * Date of Birth * MM DD YYYY Sport * Occupation * Please choose one option: Professional athlete Full-time work Part-time work Student Retired Do you have any other commitments outside of your work and/or sport? Is yes, please describe. * Height (in) * Weight (lb) * Body Fat (%) S8 Skinfolds (mm) Weight History * Please describe any weight losses or gains that you've experienced recently. Do you grocery shop and prepare your own food? * yes no (please describe below) Where do you shop for groceries? * How often do you prepare and eat meals at home each week? * Please choose one option: never a few times a week most days always How often do you dine out or order in each week? * Please choose one option: never a few times a week most days always Do you drink alcohol? * yes (please specify below) no How many times per week do you drink alcohol? Do you have any food allergies / intolerances? If yes, what are they? * Do you have any food dislikes? If yes, what are they? * Do you avoid any foods or have any dietary restrictions? Is yes, how long have you practiced this restriction? * Do you have any favorite foods or meals that you prepare? If yes, please describe. * Do you use nutritional supplements? If so, what type and brand? * Are you currently working with a trainer/coach? * yes no Do you consent to share your nutrition recommendations / plan with your coach / s&c / sports medicine? How many days a week do you train? * What is the duration of your training sessions? * Do you use any of the following in your training? * powermeter heart rate monitor GPS monitor none Do you use training software? * yes no If yes, please specify: Do you eat/drink before training sessions? * What, how much and how long before you train? Do you eat/drink during training sessions? * What and how much? Do you eat/drink after training sessions? * What, how much and how long after you train? Do you have any of the following problems associated with training and competition? Nausea before training during training after training never Vomiting before training during traiing after training never Diarrhea before training during training after training never Stomach Cramps before training during training after training never Stiches before training during training after training never Muscle Aches/Cramps before training during training after training never Heavy Legs before training during training after training never Stiff Joints before training during training after training never Poor Appetite before training during training after training never Headaches before training during training after training never Lightheadedness before training during training after training never Please describe any other problems associated with training/competitions that aren't listed above. Do you have any of the follow medical conditions? * Allergies Arthritis Diabetes Anaemia Asthma Epilepsy Coeliac disease Irritable bowel High blood pressure Sleep problems Joint / bone problems Recurrent infections Cardiovascular problems None Have you received prior nutrition advice? If so, what, when and from whom? * What are your nutritions goals/expectations? * General nutrition Performance nutrition Supplement advice Ergogenic aid advice Hydration advice Weight management Injury / rehab advice Clinical What are your performance goals? * Please describe your goals, both short term and long term: Thank you! Please review the Fuel Lab Sports Disclosure & Waiver of Liability Agreement. Download PDF Here Once you’ve read through, please sign it and send it to connor@fuellabsports.com
