Free Services
Articles
Newsletter
Self-Evaluations
Free Nutrition Report
What Our Clients Say


Professional Consultants

DONNA F. SMITH, C.C.N., C.N.
Licensed, Board Certified
Clinical Nutritionist

WILLIAM H. BRELAND, P.T., S.C.S.
Physical Therapist
Board Certified Sports Specialist

ROBERT J. WOLFF, D.C.
Chiropractor

T. ROGER HUMPHREY, M.D.
Physician

Advanced Clinical Nutrition
Wichita Falls, Tx
76309-3119
Office (940) 761-4045
Fax (940) 761-2881
E-Mail: wsnqas@aol.com

The information and services provided are for nutritional support, and not for the treatment of any medical condition or disease. By using this web site, you understand and abide by this disclaimer.

Copyright 1999
Donna F. Smith

Women Sports Nutrition Logo
Exercise and Athletic Training
Questionnaire
PRINTING INSTRUCTIONS: Print before clicking SEND NOW button. Should this questionnaire not print entirely in Portrait format, simply click on the File menu, go to Print, click the "Properties" button. A new dialog box will open. On the "Paper" tab click the radio buttion labeled "Landscape", click ok to close the dialog box. Then click OK to print.
Date:
Name:
E-Mail:

WSN Acct. No.:

INSTRUCTIONS: Whether you are on a self-designed Exercise and Ahtletic Training Program or your program is being designed and monitored by a professional trainer or coach, complete this question, initially, and each time there is a change in your training program. Order PEP Session #108 to learn how to calculate the exact number of grams of proteins, carbohydrates and fats/oils your body needs. Then each month, re-calculate your
Macro-Nutrient Daily Intake and report any changes on this questionnaire and send this updated information to us at the same time you send your other Monthly Progress Reports.


Advanced Clinical Nutrition, Wichita Falls, Tx 76309-3119
Office (940) 761-4045 Fax (940) 761-2881 E-Mail: wsnqas@aol.com
Copyright 1999 Donna F. Smith

A. TYPE OF AEROBIC EXERCISE
1. No. Hours Daily
2. No. Days per Week
3. Distance
B. TYPE OF ANAEROBIC EXERCISE
1. No. Sets
2. No. Reps in Sets
3. No. Hours Daily
4. No. Days Per Week
C. OTHER TRAINING
(Provide type, frequency, distance, duration, etc.)
1.
2.
3.

D. RECREATIONAL SPORTS
(Provide type, frequency, distance, duration, etc.)
1.
2.
3.
E. SLEEP AND REST  
1. Time You When To Sleep Last Night
2. Time You Woke Up This Morning
3. Number of Sleep Hours
4. Training Twice Daily? Number of Nap Hours
F. MACRO-NUTRIENT INTAKE  
1. Fat %
2. Carbohydrates - # of Grams
3. Protein - # of Grams
4. Fiber - # of Grams
5. Pure Water - Number of Ounces
G. ANTHROPOMETRIC - Click here  
1. Blood Pressure - Sitting
2. Blood Pressure - Standing
3. Resting Heart Rate
4. Respiratory Lung Capacity
H. SPORTS NUTRITION PRODUCTS
Provide the following information on all products except Mannatech, and those purchased through WSN - Brand Name, Dosage Per Capsule or Tablet and Company's Name, City, and State and purpose for taking. If recommended by a healthcare or fitness professional, put their name and title.
Daily Dosage
Number of Capsules or Tablets Taken
1.
2.
3.
4.
5.
6.
7.

I. COMMENTS


Click here to order PEP Session #108

Copyright, 1999 Donna F. Smith