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Challenge By Choice
Coaching In-take Form
Ready to put your goals into motion and start moving forward?
How did you hear about coaching with Us?
Friend Referral
Race Community
Word of Mouth
Run Like a Girl
Facebook
Google
Instagram
Other
Name
*
First Name
Last Name
Email Address
*
Phone
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Current Age
Gender
Male
Female
Height
Weight
Choose a plan
Package A - Programming
Package B - Programming & Nutrition
Package C - Programming & Strength
Health History
Current Injuries?
Yes
No
If yes, please describe
Past Injuries
Yes
No
Family History of Coronary Artery Disease?
Yes
No
Fainting or Dizziness
Yes
No
Seizures?
Yes
No
High Blood Pressure?
Yes
No
Heart Attack / Chest Pain?
Yes
No
Diabetes?
Yes
No
High Cholesterol?
Yes
No
Smoking (past or present)?
Yes
No
If yes, please describe:
Alcohol/Drugs?
Yes
No
Joint or Back Problems?
Yes
No
Medication?
Yes
No
Chance of being pregnant?
Yes
No
Current Treatments? (Chiro, Physio etc.)
Yes
No
If yes, please describe
Goals
Primary Goal
Date of event
MM
DD
YYYY
Distance
Secondary Goal
Date of event
MM
DD
YYYY
Distance
Long Term Goals
Race Schedule
Fitness Experience
Past Races / Personal Bests
Interests
Weekly mileage or weekly hours training currently
Number of Years Training
Do you: (check all that apply)
Have weight training experience?
Yes
No
If yes, please explain
Belong to a gym?
Yes
No
If yes, please explain
Do you attend any group classes or group training sessions?
Yes
No
If yes, please explain
Access or participate in a Spin or Indoor Cycling Program?
Yes
No
If yes, please explain
Work with a personal trainer or attend group strength classes?
Yes
No
If yes, please explain
What are you currently doing for strength training?
What is your preferred rest day?
Current Work & Trianing Schedule
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Run or Bike Specific
What is your longest run/bike currently?
What is your current weekly mileage?
Do you have experience with a heart rate monitor?
If yes, what is your resting heart rate?
Max heart rate?
Do you have experience doing speed work?
If yes, describe
Do you have experience hill training?
What do you consider your training strength?
(ex. flexibility)
What do you consider to be your training weaknesses?
(ex. hills)
Are there certain types of training you enjoy?
(ex. long & slow runs)
Are there certain types of training you dislike?
(ex. speed work)
Do you train with a partner or a group? How often? Type of workout?
Recent Competition Times & Results
10km
½ Marathon
Marathon
50km
Ultra
Stage Race
Will you have access to the following terrain?
Check all that apply
Road
Treadmill
Trails
Grass Field
Cross Training
Do you enjoy the following activities or currently participate in them?
Option One
Option Two
Other activities?
What type of fitness equipment do you have at home?
ie – treadmill, body ball, free weights, skipping rope, etc
Triathletes & Adventure Racers
Check which applies
I own my own bike.
I currently do BRICK workouts and LONG workouts as part of my training.
Describe a typical Brick workout that you would do
Which discipline(s) would you consider to be your strength?
Which discipline(s) would you consider to be your weakness(es)?
Nutrition
Are you pleased with your present eating habits?
Are you following a special diet?
If yes, please explain
Was your diet recommended by a health professional?
Have you ever been on a diet to lose weight?
Tobacco
Soda / Pop
Coffee
Alcohol
Recreational Drugs
How is your appetite?
Who usually prepares the food at home?
How many meals per week do you eat at a restaurant?
How many times per week do you eat fast food?
What time of day are you most hungry?
What eating habits would you like to eliminate, modify, or incorporate into your diet?
Describe your typical daily diet
What do you typically eat before a race/training session?
What do you typically eat after a race/training session?
How much water do you drink each day?
On average, how many of hours of sleep do you get each night?
Do you wake feeling rested?
Do you require assistance with your nutrition?
Liability Release
Is there anything else that would be important for your coach to know when designing your program and training plan? The more information that you can provide will assist your coach in assessing and making recommendations and improvements to your training.
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.
I agree
I do not agre
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?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes
No
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?
Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Yes
No
Do you know of any other reason why you should not do physical activity?
*
Yes
No
If Yes, Please explain
"I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction."
*
I agree
I do not agree
Name
First Name
Last Name
Date
MM
DD
YYYY
Witness
Waiver
Are you over the age of 19?
Yes
No
Please acknowledge your minimum monthly commitment to coaching.
*
Level I: 4-month commitment
Level II: 6-month commitment
Level III: 6-month commitment
Do you agree to giving a full 1 month (30 day) email notice before suspending or cancelling coaching.
*
Yes
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.
*
I confirm
I do not confirm
Participant Name
First Name
Last Name
Date
MM
DD
YYYY
Thank you! Jen will be in touch shortly to get you rolling with your Training Plan.
