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Blood work questionnaire
eNRG Performance Sport Dietitian
*
Bob Seebohar
Lauren Mitchell
Date
*
MM
DD
YYYY
Name
*
First Name
Last Name
Gender
*
Male
Female
Date of birth
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Telephone number
*
(###)
###
####
Email Address
*
Age
*
What are your primary health and training goals?
*
Nutrition Log
Please provide a sample day of your nutrition
*
Was this test ordered by a Registered/Sports Dietitian, Medical Professional or Coach?
Yes
No
If so, please list their contact information and location.
Please list current supplements
*
Multivitamin
Protein (powder)
Omega-3/Fish Oil
Antioxidants
Iron
Vitamin B12
Calcium
Magnesium
Vitamin D
Other
If other, please list
Please list current medications
Have you ever had any of the following?
*
Iron-deficiency anemia
Other anemia
Thyroid disorder
Eating disorder
Vitamin D deficiency
Irritable bowel syndrome
Celiac disease
Other
None
If so, please specify
Do you follow a restricted diet? If so, please explain.
How many hours per week are you currently training?
*
3-5
5-8
8-10
10-15
15-22
22+
Please rate the following using a scale of 1-5 (1 being poor and 5 being excellent)
When I wake up, I have been feeling
1
2
3
4
5
During my training sessions, I have been feeling
1
2
3
4
5
My recovery following workout has been
1
2
3
4
5
My general sense of well-being has been
1
2
3
4
5
Please describe any symptoms you are having if present
I understand this test is for the sole purpose of assessing performance biomarkers and not for the purpose of diagnosing a medical condition
*
Yes
No
Thank you!
