Personal Information
Name:______________________________________ Date:__________________
Age:_______ Sex______ Height________ Weight_______ Resting HR______
Address:_____________________________________
City:_______________________________ State:__________ Zip___________
Home phone:_____________________ Work Phone:_______________________
E-Mail address:______________________________________________________
Personal Medical/Running Information:
Medications: (Please list all over the counter as well as prescription medications that you currently take):
Have you ever been diagnosed as having any of the following conditions?
_____Cancer (please specify what kind)
_____Heart Problems
_____Hepatitis
_____High Blood Pressure
_____Asthma
_____Stroke or Transient Ischemic Attack
_____Anemia
_____Thyroid Problems
_____Diabetes
_____Allergies
_____Rheumatoid Arthritis
_____Other Arthritis (osteoarthritis, ankylosing spondylitis, etc)
_____Eating Disorder (Anorexia / Bulimia)
_____Depression
_____Other - (please be specific)
Health Risks: Has anyone in your immediate family (parents, brothers, sisters) ever been treated
for the following? Check all that apply.
_____Diabetes
_____Heart Disease
_____High Blood Pressure
_____Stroke or Transient Ischemic Attack
_____Cancer
_____Anemia
_____Arthritis
Current condition that leads you to seek professional coaching. Are you currently injured
or recovering from an injury?
Injury (diagnosis if you know it):
Date of onset:
Previous treatment regime (physical therapy? massage? ice/heat? etc.)
Previous Running Injuries: include dates
How long have you been running?________________________________________
Previous exercise or competitive history:
Racing Experience: None______ Beginner______ Experienced______
Recent Race Performance in last 6 months:
5K_________ 10K___________ other distance (specify)_____________
half marathon____________ marathon_____________
Personal Bests (list your best performances)
Distance Pace or Time
Date
Running Interests check all that apply:
_____ Fitness or fun
_____ Recreational or social racing
_____ Racing for improved performance
_____ Racing for age group or other awards
List your running and racing goals. Include future dates, distances, time goals, etc.
Describe any previous problems you've had with racing or training.
Do you perform flexibility exercises on a regular basis? If so, please list or briefly describe them below:
Do you perform strength exercises on a regular basis? If so, please list or briefly describe them below:
Shoes
Manufacturer:______________________ Model:________________ Age:_______
Recent Training
Describe your most recent 4-6 weeks of training in detail. List the miles or time spent running, your pace
or heart rate, the surface or terrain (track, hills, trails, bark chip path, etc) and any supplemental or additional training
(weights, Yoga, cycling, swimming, etc).
Example:
4 mi
34:00
rolling hills
20 min weights
