Questionnaire

COACHING CONTRACT
I hereby contract Start-Tri.Com as my personal coach for endurance sports. I agree to pay for coaching services up front at the rate of $300/month for the Tier I package, $200/month for the Tier II package or $120 a month for the Tier III package(Coach Mickey Full for 2017). I agree that should I require any one-on-one coaching outside the time included in my monthly coaching package that I am expected to pay a rate of $85 an hour for said services. I understand that these services can, at my discretion, either be billed as one complete hour or split into two half hour sessions. I understand that ALL services I require are to be billed and paid for up front before I receive said services.
WAIVER AND RELEASE FROM LIABILITY
In consideration of being accepted as a client by Start-Tri.com for the purposes of improving my fitness, I hereby attest that I am in good health, that my statements in the Athlete Questionnaire are accurate to the best of my knowledge, and that my physical condition has been verified by a licensed medical doctor. I fully understand the risk inherent in such a fitness program and accept for myself, my heirs, and my personal representatives full responsibility for personal bodily injury, death, or property losses that may occur as a result of my being a part of this program or engaging in training sessions. I hereby indemnify and save and hold harmless Jason Norman, Mickey Cassu and Start-Tri.com from any loss, liability, damage, and cost I may incur due to my participation in this program. I have read and voluntarily signed the waiver and release from liability, and further agree that no oral representatives, statements, or inducements apart from the foregoing written agreement have been made. I also understand that throughout my training Start-Tri.com may conduct various testing (sometimes blood) establishing heart rate, wattage, and pace zones to enhance and aid in making my training more efficient and effective. I understand and have been informed that these results have been calculated from test results that may not be 100% accurate and are therefore not meant to be substituted for common sense and sound judgement on my part. Although I have been instructed to follow these training zones I am under the understanding that if I am working out and feel any abnormality, physically or mentally, as a result of keeping in the instructed zone I am to stop and consult a physician immediately.
By signing below, I agree to the above Contract and Release from Liability.
Please PRINT your full name _____________________________________________________ Signature______________________________________

Date___________________________ Guardian if under 18 (Print name)_________________________________________________

Signature______________________________________Date___________________________

EMAIL THIS PACKET TO  mickey@start-tri.com

CALL  Mickey @ 908-256-1738 with any questions.  Retain a copy of this Contract and Release for your records.
PERSONAL INFORMATION
Name:____________________________________Preferred Name:_____________________________

Street Address:_______________________________________________________________________

City:____________________________________________State:_______________Zip:______________

Home Phone: (________)__________________Work Phone: (________)_________________________

Fax Number: (_________)__________________Email Address:_________________________________
At which number can we contact you?

What are the best times to reach you?

Would you prefer workouts by email, fax or internet?
Birthdate:________________Age:________

Height:______________Weight:__________
Other personal information: Occupation:_________________________________________

Hours per week:_____________

Married?

Children?

How did you hear about our coaching services? (please be specific)
Emergency Contact Information
Name:_______________________________________________________________________________

Street Address:_______________________________________________________________________

City/State:___________________________________________________________________________

Zip:_________________________________________________________________________________

Phone Number:[___]___________
Personal Physician:
Name:_______________________________________________________________________________

Street Address:_______________________________________________________________________

City/State:___________________________________________________________________________

Zip:_________________________________________________________________________________

Phone Number:[___]_____________

Medical History:
Please list any medications taken on a regular basis (prescription and non-prescription):

Allergies
Do you have any allergies or allergic reaction to any medications? Is so, please list and explain:
Past and Current Medical History
Please list any current illness, recent injuries, recent surgeries, or past medical problems or surgery of note.

Do you have, or have you had any of the following (yes / no):

Heart Disease
Asthma
Heart attack
Wheezing
Heart surgery
Diabetes
Heart murmur
Epilepsy
Hypertension
Anemia
Thyroid problems

If female, any chance you could be pregnant? Yes / No

Any special medical needs or information that the coaches should be aware of?
Yes/ No

ATHLETIC HISTORY
1. Please list the sports and activities in which you have participated most often throughout your life. Include duration participated, how long ago, how competitive your were, and any other comments. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

2. List your best (or favorite) race results, events, times, place, conditions, and so on. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

3. On average, how many miles or hours per week did you train in the last year? __________________

4. Have you ever done any strength resistance training? _____________________
4a. Do you think it helped your performance? _____________________

5. Do you feel you have ever “overtrained”? If yes, please describe the type and amounts of training you were doing at the time. _____________________________________________________________________________________ _____________________________________________________________________________________

6. Do you have any chronic injuries from any sport or activity that may flare up or should be taken into consideration in developing your training plan? _____________________________________________________________________________________ _____________________________________________________________________________________

7. What do you feel are your strengths and weakness as an endurance athlete? _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

CURRENT FITNESS LEVEL INFORMATION
1. What is your resting heart rate? ________________
If you don’t know you can test it by simply taking it when you wake up in the morning. Make sure that you give yourself 5-10 minutes of relaxing deep breathing while lying down AFTER you’ve shut the alarm off, gotten up and gone to the bathroom, and hooked up your heart rate monitor. Once you’ve done all that and 5-10 minutes has gone by relaxing you back down to an almost restful state then take your heart rate for 30 seconds. Double the number of beats and you have your resting heart rate.

2. Rate your current fitness level 1-5 (5 being the best, 1 being the worst) compared to your highest level in the past five years.
3. Describe your current training week. If you keep a training log include a copy of your last week. _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

4. Is this more, less, or the same as a normal training week for you?_____________________
5. Describe your longest single workout in the last three weeks: ________________________________ __________________________________________________________________________________
6. How many hours per week do you spend training right now? _______________________

7. Please list exactly when and how much time you have available for training? MON _____________ TUES _____________ WED _____________

THURS _____________
FRI _____________SAT ______________SUN ______________

8. How many days a week do you take off from training? _______________________
8a. Ideally, how many days would you like to take off from training? ____________________
9. Are you currently recovering from any injury or illness? Explain: __________________________________________________________________________________

PHYSICAL ACTIVITY READINESS QUESTIONNAIRE
Please explain any ‘Yes’ answers in the space below

1. Has a doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

2. Do you or have you ever had chest pain brought on by physical activity?

3. Have you developed chest pain within the last month?

4. Do you tend to lose consciousness or fall over as a result of dizziness?

5. Do you have a bone or joint problem that could be aggravated by the proposed physical activity?

6. Has a doctor ever recommended medication for high blood pressure or a heart condition?

7. Are you aware, through your own experience or a doctor’s advice, of any other physical reasons against your exercising without medical supervision?

Explain:_______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

Other health history questions:

8. Do you have any metabolic diseases controlled or uncontrolled, such as diabetes, hyperthyroidism, hypothyroidism, etc.?

9. Do you, or have you ever, smoked regularly?

10. Do you take any drugs or medications?

11. Are you, or have you recently been, pregnant?

12. Do you have high cholesterol?

13. Have you had any surgery in the past year?

14. Have you ever had an injury that caused you to stop exercising for more than a week?

15. Are you, or have you ever been, anorexic or bulimic?

16. Are there any other physical or emotional problems that may affect your training? Explain:_______________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

RACING AND PERFORMANCE GOALS
List below all the events you plan on possibly competing in this year. We understand this schedule is subject to change (in fact, we may suggest you change it). Please notify us if this schedule does change.
HIGH PRIORITY EVENTS (A RACES) These are the most important events of the racing season to you. There should be only a few of these because we will design your training schedule to taper and peak for them.

Date    Event    Distance(s)    Goal Time / Place

MEDIUM PRIORITY EVENTS (B RACES) These are the events you want to do well, but are not the focus of your season. We may rest for these events, but usually they will be thought of as race pace “workouts” to sharpen up for the high priority events.
Date    Event    Distance(s)    Goal Time / Place

LOW PRIORITY EVENTS (C RACES) These are the events of least importance to you. They are “fillers” to your season and you will most likely compete for fun and for a good workout. Do not include too many of these events, however, as they may detract from the focus of your season.
Date    Event    Distance(s)    Goal Time / Place

EQUIPMENT AND OTHER INFORMATION
1. Do you own a Heart Rate Monitor?______________If so, what brand/model?__________________

2. Do you own a Power Meter?______________If so, what brand/model?_______________________
3.    What’s the highest heart rate you’ve had while Running?_______Cycling?_______Swimming?_____

4. Please check off the equipment you have or have access to:
_____ Triathlon Bike _____ Resistance Trainer _____ Rollerblades _____ Treadmill _____ Nautilus Type Weights _____ Rowing Ergometer _____ Steep, Short Hill _____ Mountain Bike _____ Running Track (1 lap = ?__________) _____ Pool (yards or meters? ___________) _____ Open Water _____ Free Weights______  Bike computer_______

5. At the end of this month how will you judge if your training plan is working? _____________________ _____________________________________________________________________________________

6. At the end of this season how will you judge if this training plan was successful? _________________ _____________________________________________________________________________________

7. Why do you train and compete in Endurance Sports (be honest)? ____________________________ _____________________________________________________________________________________

Comments on this entry are closed.