New Client Form

Contact Information
  1. (required)
  2. (required)
  3. (valid email required)
Personal Information
  1. Sex
Health History
  1. Have you or anyone in your family had coronary artery disease?
  2. Has your doctor ever said you have heart trouble?
  3. Do you often feel faint or have spells of severe dizziness?
  4. Do you ever have chest, shoulder, neck, or arm pains after exercise?
  5. Have you ever fainted, felt dizzy, or unusually winded after exercise?
  6. Is there a good physical reason not mentioned here why you should not follow an activity program even if you wanted to?
  7. Has a doctor said that your blood pressure is too high or uncontrolled?
  8. Has a doctor ever said you have heart trouble, a heart murmur, or that you have had a heart attack?
  9. Are you diabetic, have a thyroid condition, or any chronic condition?
  10. Are you using any medications?
  11. Is your cholesterol level high?
  12. Have you ever had a complete physical exam including stress test on a treadmill or ergometer?
  13. Do you have any condition that a doctor says may limit your exercise?
  14. Have you ever smoked?
  15. Have you ever had a joint or back disorder or any current injury?
  16. Have you had surgery in last 12 months?
  17. For females, are you now, or have you been pregnant in last three months?
Athletic and Exercise History
  1. Do you currently have a strength training routine?
  2. Have you ever had an exercise related injury which caused you to stop exercising for a week or more?
Current Athletic and Exercise
  1. If you are a competitive cyclist, please list your category:
  2. Road
  3. Track
  4. Mt Bike
  5. Cyclocross
  6. Have you planned your upcoming events?
  7. What is your training week like now (Type of workout, How long, How hard)?
  8. Is the above high, normal, or low for you?
  9. In reality, how many weekly hours do you have available to train?
  10. What time of day do you expect to do most of your training during the work week?
  11. Do you have a stationery bike trainer?
  12. Do you have rollers?
  13. Do you ever train with a group? A club or team?
  14. Do you own a heart rate monitor?
  15. Do you train with a power meter?
  16. Do you know your lactate threshold heart rate( or wattage) for any sport?
Strengths and Weaknesses
  1. Rate the following 1-5, with 1 representing strength and 5 being weakness.
  2. Endurance
  3. Bike Handling
  4. Speed Skills
  5. Muscular Endurance
  6. Anaerobic Endurance
  7. Motivation
  8. Power
  9. Race Tactics
  10. Time to train
  11. Injuries
  12. Health
  13. Body Strength
  14. Flexibility
  15. Mental Skills
  16. Body Composition
  17. Nutrition
 

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