1. Have you ever suffered from any of the following:

a. Asthma                                                      YesNo

b. Diabetes                                                    YesNo

(If yes, are you insulin-dependent?)                   YesNo

c. Joint pain / swelling                                     YesNo

d. Stress                                                       YesNo

e. Headaches (particularly after exercising)          YesNo

2. Do you suffer from frequent colds / flu            YesNo

3. Do you suffer from a lack of energy?               YesNo

4. Do you take a long time to recover from

strenuous, physical exercise?                            YesNo

SECTION B - CURRENT OVERALL NUTRITION

5. Do you eat regular meals?                            YesNo

6. Do you eat a well-balanced diet?                   YesNo

7. Do you think you get the recommended vitamin

and mineral intake from the food you eat?           YesNo

 

8. Do you believe that balanced nutrition can help to

improve your focus and concentration?               YesNo

9.What does your typical daily diet consist of?:

Breakfast

e.g. cereal/toast

Mid morning

e.g. fruit, chocolate bar

Lunch

Mid afternoon

Dinner

After dinner

10.What liquids do you consume during the day? e.g. 2 x cups coffee,1 x tea, 3 glasses plain water.

11. Any cravings? e.g. sugar, carbohydrates

12. Current fuelling and refuelling routine. What to you take pre and post exercise if anything. And pre and post match etc

13.Current emphasis placed on diet and nutrition alongside training, technique and mental preparation as a means of improving overall performance. e.g. High/Some attention/Ignored

14. Do you currently take any sports nutrition foods/supplements/beverages. If yes, what do you take?

SECTION C - AREAS YOU WOULD LIKE TO IMPROVE

17. Areas of particular interest

Building stamina? Yes No

Helping my concentration Yes No

More energy, shake-off that sluggish feeling? Yes No

Help my agility, joints? Yes No

Faster recovery time  Yes No

Less injuries or illness? Yes No

Losing weight? Yes No

Gaining weight? Yes  No

Building muscle Yes  No

18.Main priority? Your biggest challenge? Area you most want to improve? Do you have questions you would like answering? Like one to one advice? A recommended programme? Other areas of interest/comments.

19.How old are you?

20.How tall are you?

21.Approx weight?

22.What is your ideal goal weight?

23.Which sport/s are you involved with?

24.What is your involvement in sports? 

Junior               

Senior              

Manager/ Trainer

25. How serious would you say you are about your sport?

1. Extremely serious              

2. Fairly serious                    

3. It is more of a hobby         

26. How serious would you say you are about maintaining long term good health by looking after your body now?

1. Extremely serious              

2. Fairly serious                    

3. It doesn’t really worry me   

27.How much would you be prepared to spend per day to achieve your goal?

Less than £1.00

£2.00

£3.00

£4.00

£5.00

Information required:

Recommended programme

Testimonials related to my sport

I have questions that I need answering

28. How did you make contact with us? Did  some one refer you, advertising, search engine, poster etc

Name 

Email 

Alternative email address

Telephone Evening 

Telephone Day

Mobile

Contact by phone or email

Best time and day to call

If email, please advise what advice you would like, using the "Main Priority" box above.  Please check your email address/advise a 2nd email address, if you have one. Email contact is unreliable!

Advice provided on landline telephones between 10am -9pm. And Saturday 10am -4pm