Nutrition Assessment Form (Page 4 of 7) in pdf

Nutrition Assessment Form Page 4

Do attempt to eat certain foods pre or post workouts? If so, describe the workout and the

foods.

Do you ever eat during training sessions? If so, describe in what type of training and what you

eat.

Is there a time of day that you notice being hungry the most?

How do you hydrate yourself during training sessions?

Do you use sports drinks? If so, what brands? Yes No

Do you have any reoccurring injuries?

Miscellaneous

Are there any nutrition issues/topics you wish to discuss or have clarified?

Yes

If yes, please state the topics.

Consent for Nutrition Counseling and Education

I hereby consent to receive nutrition education and counseling. I understand that any medical

information maintained by the WKU Health & Fitness Lab and/or the registered dietician will not

be available to any person or entity without a current authorization for release of information

signed by me, including my insurance company, employer health benefit plans, or any other

third party payer. I further understand that any information regarding my health status shall be

maintained confidentially and will not be disclosed except in aforementioned instance.

Furthermore, I will not hold the WKU Health & Fitness Lab and/or the registered dietician liable

for any illness or injury that may occur as a result of carrying out any exercise or other prescribe

health/nutrition programs.

Date: _____________ Patient name :(PRINT)________________________________________

Patient signature: ________________________Witness:________________________________

Nutrition Assessment Form Page 4