Running Questionnaire

The following questions are designed for the purpose of reviewing and determining your health history, possible risk factors, fitness and activity level.
We recommend that anyone starting a Running program should consult with a physician prior to starting.

Personal Health & Medical Information

* Indicates required field

Date *

Name: First, Last *

First

Last

Gender *

Female Male

Date of Birth *

Email *

Phone *

Height *

Weight *

BMI *

Blood Pressure *

Resting Heart Rate *

Contact in case of emergency: *

Phone *

Relation *

Cardiovascular Risk Factors

Existing Medical Conditions

Are you currently pregnant? *

Have you given birth within the last year? *

Are you currently taking any medication? *

If so, please indicate the medication and for what condition: *

Do you have any allergies? *

If yes, please indicate to what, and if medication is required: *

Injuries

Please describe your injury: *

Have you visited a health professional for your injury? *

Do you have any injuries or health concerns that effect you on a daily basis? *

Do you have any other health conditions or considerations that are not mentioned? *

In the past 12 months have you been advised by a doctor not to exercise? *

No Yes

If yes, please give details: *

Running history & goals

Please describe your current running schedule and running history: *

What are your running goals both short and long term? *

Please describe your current/goal running schedule: which days, how much time you have to run, time of day: *

Best Times or Pace:

5k *

10k *

Half Marathon *

Marathon *

Do you run with a watch/app that monitors GPS, Pace and HR? *

Yes No No, but I could get one

Current and Past Fitness Information

How would you describe your current fitness level? *

If you participate in other activities, please list the types (running, yoga, tennis, weight training etc) *

Have you ever worked with a running coach or personal trainer before? *

Do you have any specific concerns that you feel may impede your running goals (time, motivation, spouse concerns, ability etc.)? *

Any additional comments or information: *

Client Acknowledgment

By submitting this form I certify that I have fully disclosed all pertinent information in an honest and truthful manner: *

Yes No