Your Name (required) Your DOB (required)
Your Email (required) Your Phone/Mob
House/Flat Number/Name (required) Street (required) Town/City County Postcode (required)
Gender Height Weight
Is this your normal weight? YesNo Resting HR (if known) Blood {Pressure} (if known)
Please indicate if you have EVER had any of the following
Diabetes
YesNo
Pneumonia
Back/Joint Pain
Heart Murmur
Heart Disease
Angina/Chest Pain
Hepatitis
High Blood Pressure
Kidney infection
Infectious Mono
Head Injury
Other? Please give further info
Are you suffering from a heart condition (heart attack, angina, irregular heart beat, hole in your heart)?
Do you feel pain in your chest when performing physical activity?
Do you suffer from high or low blood pressure?
Are you currently taking medication to control your blood pressure or a heart condition?
Do you have a back or joint problem that could be made worse through physical activity?
Do you knowingly suffer fro diabetes?
Do you suffer from respiratory illness (asthma, bronchitis, emphysema) or have shortness of breath with mild exertion?
Are you under medical treatment for any illness?
Are you pregnant, or given birth in the last 3 months?
Please fill in any information you think is relevant
Please give details of anything you think may affect schedules and training
Please inditcate your avilability
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Hours each day
Give yourself a value score in the following areas. Be honest with yourself, there are no right or wrong answers.
Self awareness
PoorFairGoodVery GoodExcellent
Level of confidence to complete your main priority event
Ability to set goals and targets
Ability to follow through on set goals
Use of visualisation/imagery to prepare for a race
Use of self talk/thought control
Ability to pay attention/focus under stress
Ability to endure peak sensation
Ability to excel under pressure
Ability to make decisions under stress
Consistency
Ability to take recovery days without guilt
Please list any past Endurance Events completed: Runs, Sportives, Swims, OCRs or other
Event Type
When
Time
Rank/Position
Notes/Comment
Please fill in where this activity is relevant to your training.
Total weekly distance
Weekly Frequency
Longest swim
Do you plan your swim workouts?
Rate your Swimming ability (1-5)
What do you think are your limiters?
What do you think are your strengths?
What equipment do you own?
Which of the following equipment do you have access to (Please specify at home or via a gym)?
Resistance Machines
HomeGymHome & GymNo
Cable Machines
Barbells
Medicine Balls
Suspension Trainers
Battleropes:
Kettlebell
Other (please specify)
Events Planned for this Season (in order of priority) *If not sure, list any races you are considering so can discuss what will be your best options.
Race Name
Race Date
Race Type
Race Distance
Describe your current S&C program (include organised classes, frequency and duration of sessions etc):
Please use this space to give any other information you think will be useful, that isn’t included in this form.