Nyack College Sports Medicine Date:______
Female Athlete Questionnaire
Name: ______Age: ______Sport: ______
Please answer each question to the best of your ability. All answers will be kept confidential between the student-athlete & Certified Athletic Trainer.
1. How old were you when you had your first menstrual period? ______
2. Do you have a menstrual cycle? Yes ______No ______If no, how long has it been since you had one? ______
3. How often do you have a menstrual cycle? monthly______other______
4. How long do your periods last? ______
5. How many menstrual cycles have you had in the past 12 months? ______
6. Do you ever have trouble with heavy bleeding or abnormal spotting? ______
7. Do you ever experience excessive cramping with your period? ______
8. Do you currently take birth control or hormone therapy pills? Yes ______No ______
If yes, please list name of pill(s)/medication(s)______
9. Have you ever been treated for anemia (low blood iron)? Yes ______No ______When? ______
10. How many meals do you eat a day? ______How many snacks? ______
11. What have you had to eat and drink in the last 24 hours? ______
______
12. Do you regularly miss meals?Yes ______No ______If yes, how often? ______
For what reason?______
13. Do you limit or carefully control the foods that you eat? Yes ______No ______
In what way?______
14. Are there certain foods or food groups that you do not eat? ______
Please explain: ______
15. Please check if any apply to you.
_____Vegetarian? _____Vegan? (no animal products)
_____Ovo-vegatarian? (eggs, but no dairy)_____Ovolaco-Vegatarian? (eggs & dairy)
_____Laco-vegatarian? (dairy, but no eggs)_____Pescetarian? (fish & seafood)
_____Flexitarian? (reduced amount of animal meat)_____No Red Meat?
_____Other, please explain-______
-If you check any of the above, when did you begin this lifestyle? ______
16. Have you ever been on a diet?Yes ______No ______How long? ______
Why? ______
17. Are you currently or have you ever used dietary supplements, laxatives, diuretics, weight control pills, or vomited to control your weight?
Yes ______No ______Please explain: ______
18. Do you ever eat in secret?Yes ______No ______Explain: ______
19. Do you feel you have lost control over what you eat?Yes ______No ______
Please explain: ______
20. Have you lost or gained a significant amount of weight? Yes ______No ______When?______
How much?______Why?______
21. Do you have rapid increases or decreases in your body weight? Yes ______No ______Explain: ______
22. Do you worry about your weight? Yes ______No ______In what way? ______
23. Are you satisfied with your weight? Yes ______No ______If not, what would you like your weight to be? ______
24. What do you do to control your weight?______
25. Has anyone ever suggested you lose weight or change your eating habits?Yes ______No ______
Explain: ______
26. Do you lose weight to meet image requirements for your sport?Yes ______No ______
27. Do you think your performance is directly affected by your weight? Yes ______No ______
If so how?______
28. Have you ever been diagnosed and/or treated for an eating disorder?Yes ______No ______
If yes, are you currently under the supervision of a doctor? Yes ______No ______
29. Do you have any questions or concerns about maintaining a healthy weight and body image? ______
______
30. Do you regularly take vitamins/minerals? Yes ______No ______What Kind?______
31. Do you often feel tired and/or have low levels of energy?Yes ______No ______
32. Do you feel you have adequate energy throughout the day?Yes ______No ______
33. Do you feel you have enough energy for your sport?Yes ______No ______
34. Have you ever had a Bone Density study done? Yes ______No ______If yes, when? ______
35. Have you ever had a stress fracture(s)? Yes ______No ______Where/When? ______
36. Do you have a stress fracture now?Yes ______No ______Where/When? ______
37. Have you ever broken a bone?Yes ______No ______Where/When? ______
Please let us know if you have any questions, comments, or need further information regarding the questions listed above.
Please date and sign below certifying that the answers to the questions above are complete, correct and true.
DATE:______SIGNED:______
Student-Athlete’s Signature