Ready to put your goals into motion and start moving forward?


Name *
Name
Phone
Phone
Address
Address
Choose a plan
Health History
Current Injuries?
Past Injuries
Family History of Coronary Artery Disease?
Fainting or Dizziness
Seizures?
High Blood Pressure?
Heart Attack / Chest Pain?
Diabetes?
High Cholesterol?
Smoking (past or present)?
Alcohol/Drugs?
Joint or Back Problems?
Medication?
Chance of being pregnant?
Current Treatments? (Chiro, Physio etc.)
Goals
Date of event
Date of event
Date of event
Date of event
Do you: (check all that apply)
Have weight training experience?
Belong to a gym?
Have access or participate in a Masters Swim Program?
Access or participate in a Spin or Indoor Cycling Program?
Work with a personal trainer or attend group strength classes?
Current Schedule
Run or Bike Specific
(ex. flexibility)
(ex. hills)
(ex. long & slow runs)
(ex. speed work)
Recent Competition Times & Results
Will you have access to the following terrain?
Check all that apply
Cross Training
Do you enjoy the following activities or currently participate in them?
ie – treadmill, body ball, free weights, skipping rope, etc
Triathletes & Adventure Racers
Check which applies
Nutrition
Liability Release
The information that I have given is true and correct to the best of my knowledge. Should any conditions change, I agree to notify my coach immediately.
Par-Q & You
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Do you feel pain in your chest when you do physical activity?
In the past month, have you had chest pain when you were not doing physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction." *
Name
Name
Date
Date
Waiver
Are you over the age of 19?
I CONFIRM THAT I HAVE READ AND UNDERSTOOD THIS RELEASE AGREEMENT PRIOR TO SUBMITTING IT, AND I AM AWARE THAT BY SUBMITTING THIS RELEASE AGREEMENT I AM WAIVING CERTAIN LEGAL RIGHTS WHICH I OR MY HEIRS, NEXT OF KIN, EXECUTORS, ADMINISTRATORS, ASSIGNS AND REPRESENTATTIVES MAY HAVE AGAINST THE RELEASEES.
Participant Name
Participant Name
Date
Date