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Contact Info:
   
First Name
 
*Last Name
 
*Address 1
 
Address 2
 
*City
 
*State/Province
 
*Zip/Postal Code
 
Country
 
Work Phone
 
Home Phone
 
Other Phone
 
FAX
 
E-mail
 
Date of Birth
 
Gender
  Male     Female
Referred by
 
Occupation
 
Hrs. worked weekly
 
Married?
 
Spouse's Name
 
Children's Names
 

 
GOALS - I work with people at all levels. Please tell me your interests. This can range from getting in shape to setting a PR, completing a Marathon or winning a race.

 

 

PR Distance
Event Name & Date
PR Time
5 K
5 Miles
10 K
15 K
20 K
1/2 Marathon
Marathon
50 Miles
100 K
100 Miles
24 Hour
 
If you've run any Triathlons, please list them along with your times (or PRs)

 

 

Training Information
What are the names & dates of the races you are interested in?  
How long have you been running/training?  
Current weekly mileage  

Please describe your training regimen over the last 2 weeks.  
Slow training pace (min/mile)  
Fast training pace (min/mile)  
How many days per week do you normally run?  
How many hours each day do you have for training?    
Sun  Mon  Tues  Wed  Thurs  Fri  Sat
Do you train in the morning or evening?   Morning Evening
What is your longest bike ride? run? swim?  
What kind of cross training do you do?  
Have you ever run on trails?  
Do you have access to a track?   Yes No
Have you ever done any speed work on a track?   Yes No
If yes, does the track have stadium stairs that are runnable?   Yes No
Do you like to train with others?   Yes No
Do you belong to a gym?   Yes No
If yes, does the gym have these things:    
  Spin Class:   Yes No
  What days do they offer them? M Tu W Th F Sa Su
  Yoga or Stretch Class:   Yes No
  What days do they offer them? M Tu W Th F Sa Su
  A Sauna   Yes No
  EFX Machine (Elliptical trainer)   Yes No
  SM - Stair Master   Yes No
  Versa Climber   Yes No
  Rowing Machine   Yes No
  Core Strength Class:   Yes No
  What days do they offer them? M Tu W Th F Sa Su
  Circuit Training Machines   Yes No
  Free Weights   Yes No
  List all Cardio Classes available to you.  
       
     
Do you have a pull up bar?   Yes No
Do you own a jump rope?   Yes No
Do you lift weights?   Yes No
Do you consider your training area to be:   Flat Hilly Rolling Hills
Have you ever trained with a heart rate monitor?   Yes No
If you use a heart rate monitor, what is your heart rate during easy runs?  
If you use a heart rate monitor, what is your heart rate during hard runs or races?  
What is your resting heart rate?  

If you have ever participated in any type of physiological testing
(Max VO2, Stress test, anaerobic threshold, etc.), please provide details.


Triathletes
What kind of swimming facilities do you have access to?  
Do you have access to a Masters Swim Program?   Yes No
If yes, days per week:  
What kind of bicycle do you have?  
Do you own an indoor bike trainer?   Yes No
What event distance do you prefer?  
     
Diet / Nutrition
Please describe your typical daily diet (breakfast, lunch, dinner and snacks)  
What do you typically eat BEFORE a race or training session?  
What do you typically eat AFTER a race or training session?  
What sports drink do you use?  
Do you take vitamins?   Yes No
If yes, please describe:  
     
Medical History
Height  
Weight  
Blood Type (if known)  
If any of the following applies to you, please provide more details.
You or someone in your family had coronary artery disease  
You experience chest, shoulder, neck or arm pains after exercise  
You have fainted, felt dizzy, or unusually winded after exercise  
A doctor has said that your blood pressure is too high or uncontrolled  
A doctor has said that you have heart trouble, a heart murmur, or that you have had a heart attack  
You are a diabetic, have a thyroid condition or any chronic condition  
You are using medication
List all medication(s) you are using
 
You have high cholestrol  
A doctor has said you have a condition that may limit your exercise  
You have smoked
Note when you stopped
 
You have a joint or back disorder  
If you've ever had a running related injury, please provide more details, including how you treated it.  
* I agree to the three-month initial coaching commitment.