• Client Intake and Health Screening Form

    Affinity Sports Nutrition

  • Please complete the questions in this form as accurately as possible. It may take 15-20 minutes to answer all questions

    This health screening is designed to assess your medical and lifestyle history, identify any factors that may require referral to a healthcare professional, and ensure that sports nutrition coaching is appropriate, safe and within my scope of practice.

  • General questions

  • Format: 0000000000.
  • Date of birth *
     - -
    2 digit day, 2 digit month, 4 digit year
  • For health screening purposes, please select your sex assigned at birth:*
  • Do you have any medical conditions that affect your ability to exercise or follow a nutrition program?*
  • Approximately how much water do you drink each day?*
  • Do you have any current injuries?*
  • Any food allergies or intolerances?*
  • Do you eat at least one serving of fruit and three servings of veggies a day?*
  • Do you drink more than 10 standard drinks a week?*
  • Do you currently smoke/vape?*
  • Are you working towards a specific event or date?*
  • Is your occupation sedentary?*

  • Relationship with food

  • Do you ever experience periods of uncontrolled eating, and guilt/shame associated with food?*

  • Health and Wellbeing Self-Assessment

  • Medical History

  • Have you had recent bloodwork conducted?*
  • Were any results outside the normal reference range?*
  • Are you on any medication?*
  • Have you ever been diagnosed with any other medical conditions not already mentioned?*
  • Do you suffer from or have been diagnosed with any eating disorder?*
  • Have you been diagnosed with hypertension or high cholesterol?*
  • Do you have a history of yoyo dieting?*
  • Have you been diagnosed with either Type 1, 2 or pre diabetes?*
  • Have you experienced unexplained loss of muscle and bodyfat gain?*
  • Have you been diagnosed with stress fractures, lower peak bone mass, osteoporosis or osteopenia?*
  • Do you suffer from, or have you been diagnosed with heart disease, myocardial infarction (heart attack), atrial fibrillation, bypass graft, or valve replacement?*
  • Have you had any gastrointestinal surgeries within the last 12 months?*
  • Are you, or have you been pregnant within the last 6 months?*
  • Do you have amenorrhoea (irregular or absent menstrual cycle)?*
  • Have you reached menopause?*
  • Are you on contraception?*
  • Have you been diagnosed with PCOS or Endometriosis?*
  • Do you experience IBS-type symptoms (bloating/distention, constipation, diarrhoea)*
  • Should be Empty: