Performance Index

Complementary Nutritional Health and Fitness Evaluation

Fill out the following form and take advantage of a complementary 20 minute consultation with Dr. Kleinwaks to discuss your health, fitness or nutritional needs. Expect an email or call from Dr. Kleinwaks's staff to set up a convenient time to talk.

First Name:

Last Name:

State:		DOB:		Email:		Phone:
How did you hear about us:

To evaluate you correctly we need some basic information. The more honest you are with the answers you give, the more accurate this will be.

Rate your endurance:
terrible
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2
3
4
5
6
7
8
9
10 very good
Rate your upper body muscle strength:
very weak
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2
3
4
5
6
7
8
9
10 strongest
Rate your lower body muscle strength:
very weak
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2
3
4
5
6
7
8
9
10 very strong
Rate your energy day to day:
very low energy
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2
3
4
5
6
7
8
9
10 very high energy
Rate your ability to stay focused for long periods of time:
very difficult focusing
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4
5
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7
8
9
10 locked in the entire time
How often do you get tired within an hour after eating a big meal:
never
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5
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9
10 very often
How often do you get colds or sick:
rarely ever
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9
10 six or more times a year
How would you rate your confidence:
poor
1
2
3
4
5
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9
10 excellent
When you are faced with negative results or outcomes, you:
Immediately forget and move on
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2
3
4
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8
9
10 Carry it like a ton of bricks
Are you overweight: Are you underweight:
How often do you exercise:
Which of these do you take on a regular basis:

Multivitamin B-complex Vit C Vit D Protein shakes
Creatine Post workout drink Mineral water
How often do you eat meat/animal products:
How often do you eat dairy products. (milk , yogurt, cheese or ice cream):
On average how many helpings of fruits and veggies/day do you eat:
How many times a day do you eat foods with sugar in them(fruit not included):
What liquids do you drink normally and before exercising:

Gatorade Soda Tap Water Vitamin Water Mineral Water Coconut Water
Juices Coffee Tea Herbal Tea Ice Tea Lemonade Other:

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