Nutrition Questionnaire

Please fill out the following survey to tell Barbara a little bit about your dietary habits. Barbara will contact you for your free consultation.

1) Please list your sport(s):

2) Are you presently at your goal weight?

      yes
      no

3) Are you following any special diet?

      yes
      no

If yes, than please describe the diet below:

4) How many meals/snacks do you eat per day?

      1-2
      3-4
      5-6
      7 or more

5) How often do you eat out per week?

      1-2 times a week
      3-4 times a week
      5-6 times a week
      7 or more times a week

6) Please rate the following from 1-10 (10 being the highest energy)

  a) How is your overall energy level?
      

  b)How well do you recover after a workout/competition or game?
      

7) Please indicate which supplements you use if any:

      Multivitamin
      B-complex vitamins
      Iron
      Calcium
      Magnesium
      Protein powders/drinks
      Amino acids
      CreatineHMB
      Andro/DHEA
      Ephedra/Ma huang
      Caffeine
      Pyruvate
      Sports drinks (Gatorade, Cytomax)
      Energy bars

8) Where did you hear about Barbara?

9) Do you have any specific comments or concerns?

 

Your name:
Phone number:
E-mail:
Preferred method of contact:
Best time to contact:

Thank you for taking the time to fill out this form.


Sitemap | Privacy Policy | Terms and Conditions

Barbara Lewin R.D., L.D. Sports Nutritionist

© 2004 Sports-Nutritionist.com. All rights reserved. Design by Exclusive Concepts