QUESTIONNAIRE | Oceanforce

Unleash Your Physical & Mental Potential

Baseline Performance Questionnaire

Welcome to OceanForce Sports Performance, please fill in your personal details and answer the following questions regarding your current performance & nutrition intake. Should you have any questions feel free to call 0275168476 or email caroline@oceanforce.co.nz

Please ensure that this form is completed at least 2 days before you come in so that your valuable time & money is not wasted collecting personal details etc.

If this Questionnaire is not completed prior to the initial consult, the appointment will have to be postponed to a later date.

Step 1 of 6

16%

Personal Details
Name*
First Last
Address*
Street Address Address Line 2 City Region Post Code Country
Home Phone
Mobile Phone
Email*
Age
Gender
How did you hear about us?*
If Other please specify

GP's Details
GP's Name*
GP's Phone
Can we contact your GP to discuss your health needs*

What Sports are you in to?
What sports are you involved in?*
What training are you doing?*
Who's on your training support team?*
What medication or supplements are you taking?*
How can we help?*

Diet & Nutrition
What do you love to eat?*
What do you hate to eat?*
Are there any foods that make you feel bloated, nauseous or cause diarrhoea or constipation?*

Breaskfast
What would you normally eat for breakfast? NOTE: Please include time of day meals are eaten.
Lunch
What would you normally eat for lunch? NOTE: Please include time of day meals are eaten.
Breakfast Time

: HH

MM
Lunch Time

: HH

MM
Breakfast
Lunch
Dinner
What would you normally eat for dinner? NOTE: Please include time of day meals are eaten.
Snacks
What would you normally eat for snacks? NOTE: Please include time of day meals are eaten.
Dinner Time

: HH

MM
Snack Time

: HH

MM
Dinner
Snacks

What do you drink?
How many glasses of the following do you have in a day?
Water
Tea/Coffee
Juice
Fizzy/Energy Drinks
Alcohol
Thank you - Please Submit
Thank you for taking the time to fill in this questionnaire. We look forward to meeting you here at OceanForce Sports Performance Clinic.

Unleash Your Physical & Mental Potential

Unleash Your Physical & Mental Potential

Unleash Your Physical & Mental Potential

Unleash Your Physical & Mental Potential

Unleash Your Physical & Mental Potential

Unleash Your Physical & Mental Potential

Baseline Performance Questionnaire

Step 1 of 6

Personal Details

GP's Details

What Sports are you in to?

Diet & Nutrition

Breaskfast

Lunch

Dinner

Snacks

What do you drink?

Thank you - Please Submit

If you want to win, get in touch and start fuelling your body for performance and success