New Client Health Form

Name *

First Name

Last Name

Phone *

(###)

###

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Are you currently under the care of a doctor for an illness or injury? *

Yes

No

Are you currently working with any professional healthcare providers related to your sport?

Nutritionist

Athletic Trainer

Skills Coach

Physical Therapist

Kinesiologist

Psychologist or Psychiatrist

Other

Do you suffer from any of the following, check all that apply.

Digestive Issues

Allergies

Food Sensitivities or Intolerances

Asthma

Headaches

Muscle Soreness or Cramps

Frequent Colds or Sinus Infections

Irregular Periods

Other

Have you taken antibiotics in the last two years, or frequently as a child?

Yes

No

Where do you typically eat meals? Click all that apply *

Home Cooked Meals

School or Team Cafeteria

Fast Food/Take Out

Convenience Snacks on-the-go

Other

Do you have access to a kitchen? *

Yes

No

Do you consume any of the following?

Alcohol

Coffee

Caffeinated Sports Drinks or Pre-workout

Cigarettes

Vape

Chew/Dip/Nicotine

Marijuana/THC

Do you have trouble falling asleep or staying asleep? *

Yes

No

Sometimes

Do you practice any forms of Mindfulness or Relaxation Techniques?

Meditation

Breathing

Visualization

Gratitude

Other

Which areas of stress do you feel play a significant role in your life?

College Commitment

Professional Draft or Contract

Classes/Grades

College or Graduate School Admissions

Risk of Injury

Playing Time

Family Pressure

Relationships

Finances

Living Environment

Social Life

Busy Schedule

Sleep

Weight

Other

Are you currently in a relationship?

Yes

No

What forms of social media do you use? *

Instagram

Twitter

Snapchat

Facebook

Other

None