Sports/Clinical Nutrition Assessment Form

Sports/Clinical Nutrition Assessment Form
Name*

First NameLast Name
Age*
Gender*

MF
Sport(s) Played*
Date

MonthDayYear
Date of form completion, not date of birth.
Have you had a blood test done recently? (In the last 6 months)*

YesNo
If yes, please upload the blood test report here.

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Any deficiencies found in the blood test?
(eg. B12, D3, Iron deficiency).
Have you ever been successful at any of the following. Pick none if the answer is no.*

Gaining weightLosing weightGaining muscleLosing fatMaintaining weightNone
Do you think you need to change your body composition in any way?*

YesNo
Would you consider yourself to be on any of the following diets?

VegetarianVegetarian (eats eggs)Non-vegetarianVeganLow carbohydrateLow fatAny otherNone
Any food allergies?*

YesNo
If yes, please mention
Do you have any religious/cultural food preferences?
eg. No meat/egg on tuesday & saturday
Do you generally feel energetic throughout the day?*

YesNo
How many hours of sleep do you get every night, on average?*
Please mention your sleep timings as well.

Urine Colour (Refer to urine chart at the end of this page)*

	1	2	3	4	5	6	7

1 is , 7 is

Please mention any supplements you take on a regular basis.
Mention supplement(s) name along with the name of the brand(s).
Please enter your daily training routine with the number of hours trained. Row 1 is for morning sessions and Row 2 is for evening sessions.*
Please write any additional nutritional and fitness goals you have.
How many Litres of fluids do you consume on average, daily? *
This includes fluids like milk, juices, sports drinks etc in addition to plain water.
Importance of Logging your Diet/ Diet Recall

In order to conduct a detailed and thorough assessment, it is important for us to know your regular dietary intake and patterns, including timing, quantities etc.

Therefore, we recommend that you fill your 3-day diet recall in this form.

If there is a time constraint or you are unable to fill the 3-day diet recall, we recommend logging your diet for 24 hours.

If you are already logging your diet on an app, you can upload the screenshot for any 3 days (preferrably 2 weekdays and one day from Saturday/Sunday).
Do you log your diet regularly on a diet tracking platform/diary/notes?*

YesNo
Would you like to share the diet recall of 3 days from the above platform/means you use?

YesNo
Please upload screenshots of 3 days of diet recall from the diet tracking platform.

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How would you like to log your diet?

Fill up the Diet Recall of 3 days in this formUpload Screenshot or picture of Diet Recall of 3 days from a diet-tracking app/hand-written logLog recall of 24-hours in this formUpload picture of 24-hour recall on this form
Useful Guidelines for Filling Diet Recall below
Example of 3 day diet recall
Please mention date of Day 1 entry.

MonthDayYear
DAY 1 NUTRITION INTAKE
Please mention date of Day 2 entry.

MonthDayYear
DAY 2 NUTRITION INTAKE
Please mention date of Day 3 entry.

MonthDayYear
DAY 3 NUTRITION INTAKE

Food Frequency Table

	Never	Less than once/ month	1-3 per month	Once a week	2-4 per week	5-6 per week	Once a day	2-3 per day	4-5 per day	6+ per day
Rice
Wheat
Bread
Oats
Millets/ other grains
Lentils
Beans
Chickpeas
Soya bean
Fruits
Green leafy vegetables
Potato/ sweet potato
Other vegetables
Milk
Curd
Paneer
Eggs
Chicken
Fish
Other meats
Sea food
Nuts
Seeds
Alcohol
Tobacco
Junk Food
Outside/ delivered foods

Should be Empty: