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Intake Form

This form provides basic relevant information. In order that we can provide you with the highest quality coaching possible, please complete the entire form to the best of your ability. This begins the coaching dialogue and process.

A. General Information

In which sport do you desire training?

Which training plan have you selected?

 

Name
Address
City
State
Zip
Date
Home Phone #
Work Phone #
Cell Phone #
Fax #
E-mail
Gender
Date of Birth
Age

B. Medical History

Please list any medications, drugs or nutritional supplements that you are presently taking.

Is your physician aware that you are participating in this exercise program?

Explain any past injuries or surgeries affecting working out. Include dates or time frames as best possible.

If currently exercising, briefly describe your program:

 

C. Physiology

What is your current body weight?

What is your height?

Do you know your numerical value for V02 max (ml/kg/)?

What is your Body Mass Index (BMI)?

Do you know your current body fat percentage?

If you use a heart monitor:

What is the max heart rate (running) you have seen in the past 6 months?

What is the max heart rate (running) you have ever seen?

 

D. Training Information

How many years have you been running?

How many miles per week are you running?

How many hours per week are you running?

What is your average run length in miles and time?

What is your long run length in miles and time?

What are your PRs (Personal Records) for the following distances with approximate dates? (Leave blank if not applicable.)

Race
Times
Dates
400
800
1600
3000 (3K)
3200
5000 (5K)
10K
10 Mile
Half-Marathon
Marathon
Ultra-Distance/Event
Other Distance/Event
Sprint Tri
Olympic Tri
Half Ironman Tri
Ironman Tri

Describe your typical warm-up routine here.

E. Performance Support Information

When was the last time you replaced your shoes?

Are there specific exercises you are unable to perform? If so, what are they?

Name of fitness club membership (if applicable)?

Do you have any exercise equipment at home? Please list.

Describe how much time are you willing to allocate to fitness activities in hours per day; weekdays; on weekends. Please include information about the time of day you prefer to workout as well as your work schedule, frequent travel, etc.

Do you consider yourself a beginner, intermediate or advanced athlete?


What are some secondary activities you want to incorporate into your training plan?

What type of events do you want to focus on and what are the distances of these events?

List races you intend participating in during the next 12 months. Please list events, dates, location, and terrain if known. Please prioritize events in order of importance.

What are your specific goals for the events mentioned above (finish times, etc.)?

How many events did you participate in last year?

Do you live in region where the weather can affect training? Please describe.

Do you own an indoor trainer or treadmill?

What other athletic activities have you been doing for the past 2 months and how much of each?

What are your expectations regarding this relationship?

If you have any specific goals/concerns/etc., please list them.

Why do you participate in races and/or training?
(To select multiple items: ctrl click Windows - cmd click Mac)

What form of communication do you want from your coach?
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When would you like your training program to begin?

Please list any additional comments and or concerns that will assist us in helping you reach your goals.

F. Payment Policy

The programs are based on monthly cycles. We request athletes to commit to a minimum of 4 months(17 weeks). New programs may see immediate results but results are far superior over longer periods. These payments need to be made before the beginning of the next training schedule. The training schedule is but one part of the coaching package.

G. Waiver and Release of Liability, Assumption of Risk and Indemnity

Athletes over the age of 18.
I acknowledge that by signing this document, I am releasing RxRunning and Mindset for Performance LLC and all of its respective agents and employees from liability. I have been advised by RxRunning and Mindset for Performance LLC that it is my responsibility to seek a physicians advise before beginning this or any exercise or training program. By signing this document I hereby fully assume any and all risks associated with my participation with RxRunning and Mindset for Performance LLC. I hereby waive, release, discharge, hold harmless, and indemnify RxRunning and Mindset for Performance LLC from any and all claims arising, and from any and all damages which may be sustained directly or indirectly or out of my association with RxRunning and Mindset for Performance LLC.

Athletes under the age of 18.
Please read the Waiver and Release of Liability for Athletes over the age of 18 and then read this section.
In addition to the waiver and release of liability, if the athlete is under the age of eighteen (18), written permission in the form of a signature to this agreement by the minor athlete's parent or legal guardian is required prior to the minor athlete's participation in these services. Minor athlete's parent and/or legal guardian, hereby waive, release, discharge, hold harmless, and indemnify RxRunning and Mindset for Performance LLC and all its respective agents, employees, and all other associates from any and all damages which may be sustained directly or indirectly or out of his/her association with RxRunning and Mindset for Performance LLC.

H. Required

By selecting the I agree box below, I (participating athlete or legal guardian of a minor athlete) understand and agree to the terms of this waiver and the payment policy (section F and section G). I AGREE

  

CHECK THE I AGREE BOX BEFORE SUBMITTING FORM