RUNNER CONSULTATION
Name
Home Phone
Cell Phone
Street Address
City		Zip
Email		DOB
Sex	Female Male
Marital Status
Height   Weight   Waist/Dress Size
How did you hear about me?
Occupation   Employer   Phone
Emergency Contact   Relationship   Phone
Primary Physician Phone
May I send a copy of your consultation to your primary physician?   Yes No
What are your running goals?
What are your flexibility goals?
What are your nutrition goals?
Why are you choosing to utilize a running coach?
Health History Questionaire Please select Y or N to any of these past or present problems. If yes, please explain why.
Arthritis   Yes No
Depression   Yes No
Diabetes   Yes No
Smoker   Yes No
Are you taking any type of vitamins?   Yes No
What kind?
Are you taking any type of medication?   Yes No
What kind?
Are you currently exercising?   Yes No
Days per week: Minutes per day:
Describe exercise or activity:
Your current fitness level?   Beginner Intermediate Advanced
Have you done cross-training in your workouts?   Yes No
What types?
Have you used heart rate training before?   Yes No
What types?
Running Client Questionaire Please answer and be specific as much as possible to get to know your past and present history to help me set you up on a Challenging but Safe program.
How long have you been a runner?
Have you used heart rate training before?   Yes No
What types?
Did you run in any type of school?   Yes No
If so, What Grade Levels?
Have you had or do you currently have a running log?   Yes No
What is the highest mileage that you have ever attained in your running in a :
Day? Week? Month? Year?
Have you ever had or currently have any injury/s?   Yes No
If so, please explain each injury in detail concerning cause, symptoms, and treatment.
Have you ever run twice a day?   Yes No
What types of training do you like?
What types of training don't you like?
What types of surfaces have you run in/on?
Indoor Track Outdoor Track Pool Roads Trails Treadmill
What kind of running shoes do you wear for your training?
What kind of running shoes do you wear for racing?
Have you ever used weight training in your running?   Yes No
What types?
Have you had a chiropractor for your running?   Yes No
If so, please explain.
Have you had massages for your running?   Yes No
If so, please explain.
What are the most days you can run each week?
What are the least days you can run each week?
What is your favorite time/s to run?
What are your favorite places to run?
What kind of weather runner are you?
Do you stretch for a race or training run?   Yes No
When?
What is your favorite distance to race and why?
What is your least favorite distance to race and why?
What was the last race that you ran, what was the distance & the time that you ran it?
What is your PR for these distances & give the date & time that you ran them in?
200 meters 400 meters 800 meters 1000 meters 1 mile 2 miles 5 k 4 miles 5 miles/8 k 10 k 15 k 10 miles 20 k 13.1 miles 25 k 26.2 miles Ultra Marathon
Informed Consent
I,
voluntarily consent to engage in a biomechanical stride analysis, cardiovascular fitness test, exercise prescription program, flexibility test, muscular endurance test, muscular strength test, and a running program. I understand any of these exercises or tests may involve me exerting myself beyond my normal exercise routines.
I,
understand that certain physical changes could occur to me during these exercises and tests. Such occurrences that could happen are abnormal blood pressure, back problems, cardiac arrest, fainting, heart failure, knee problems, a reaction to any current medications that are being taken by the client, and any shoulder problems. Even though I will be observed by Tod Esquivel during testing and training, I understand that I am responsible for monitoring my own condition throughout the procedures, and should any unusual symptoms occur, I will cease participation and inform Tod Esquivel of any and all symptoms.
I,
also understand that an emergency could happen. In the event an emergency occurs, I am financially responsible for any emergency services that might be deemed necessary.
I,
agree to assume all risks of the exercises and fitness testing and hereby release and hold harmless Tod Esquivel from all health claims, suits, losses, or cause of action for damages, injury or death, including claims for negligence, arising out of or related to my participation in the fitness assessment.
Cancellation Policy
I,
agree to call 1 hour before the scheduled workout to cancel my personal training session with Tod Esquivel or I will lose that training session.
Tardiness
If a client is late, he/she will be trained for the remainder of his/her session only. If Tod Esquivel is late more then 10 minutes, that session will be given at no charge to my client.
No Shows
If you, my client does not show up for an appointment you will be assessed a full session charge. If Tod Esquivel does not show up, I will add an extra session at no charge to you.
I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. To the best of my knowledge, the information I have provided is accurate. I will inform Tod Esquivel of any changes in my health status as it changes in the future.
Signature Date
Guardian (if under 18) Date
Witness Date