Sports/Clinical Nutrition Assessment Form

Name

First NameLast Name

Age

Gender

Sport(s) Played

Date

Date of form completion, not date of birth.

Have you had a blood test done recently? (In the last 6 months)

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.

Do you think you need to change your body composition in any way?

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

Any food allergies?

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?

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?

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

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?

Useful Guidelines for Filling Diet Recall below

Example of 3 day diet recall

Please mention date of Day 1 entry.

DAY 1 NUTRITION INTAKE

Please mention date of Day 2 entry.

DAY 2 NUTRITION INTAKE

Please mention date of Day 3 entry.

DAY 3 NUTRITION INTAKE

Food Frequency Table

Rows	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