Step 1 of 9 11% Name*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone Numbers*specify type cell, home, work etcBest time to reach you*Email* Enter Email Confirm Email Which coach are you interested in working with?*Head Coach Richard PadyAssociate Coach Angela QuickAssociate Coach Alex VanderLindenNo preference Physical and Athletic DetailsGender*MaleFemaleDate of Birth (mm/dd/yyyy)* HeightWeightWalking pulse or resting heart rateWhich sport are you seeking coaching forWhich level of coaching are you currently at?If you are signing up for a training plan, what race are you gearing-up for and what is the race date?Date to start training program* Non-Athletic DetailsOccupationHours Worked WeeklyMarital StatusSingleMarriedDo you have children or dependantsYesNo Your Health HistoryDo you have, or has anyone in your family ever had coronary artery disease*YesNoPlease explain*Do you ever experience chest, shoulder, neck, or arm pains after exercise*YesNoPlease explain*Have you ever fainted, felt dizzy, or unusually winded after exercise*YesNoPlease explain*Has a doctor said that your blood pressure is too high or uncontrolled*YesNoPlease explain*Has a doctor ever said you have heart trouble, a heart murmur, or that you have had a heart attack*YesNoPlease explain*Are you diabetic, have a thyroid condition, or any chronic condition*YesNoPlease explain*Are you using any medications*YesNoPlease explain*Is your cholesterol level high*YesNoPlease explain*Have you ever had a complete physical exam including stress test on a treadmill or ergometer*YesNoPlease explain*Do you have any condition that a doctor says may limit your exercise*YesNoPlease explain*Have you ever smoked*YesNoPlease explain*Have you ever had a joint or back disorder or any current injury*YesNoPlease explain*Have you had surgery in last 12 months*YesNoPlease explain*Are you now, or have you been pregnant in last three months*YesNoPlease explain* Athletic HistoryList your favorite sports and years of participationDo you currently have a strength training routine, if yes please describeRate your familiarity with strength training routinesHave you ever had an exercise related injury which caused you to stop exercising for a week or moreYesNoPlease explain*For multisport and running, list your best race times, with splits if possible. Cyclists and MTBers list race category and years at that category. Your Current Athletic Information1. Have you planned what races you will compete in for next season?YesNoList your 3 most important goalsRank them 1-2-3At the completion of our season, how will we know if we were successful*What is the single most important thing we must accomplish*What is your current training week like now? Please list type of workout, how long and hard.Monday workoutTuesday workoutWednesday workoutThursday workoutFriday workoutSaturday workoutSunday workoutIs this volumeLowNormalHighPlease provide an example of a typical HIGH VOLUME week from your training log.What is your longest workout in the last 3 weeksHow many weekly hours do you have available to train. Be realistic.Please enter a value between 0 and 40.What time of day do you expect to do most of your training during the work week?Where do you plan to swim*When do you plan to swim?AMPMIf pool swim, what sizeDo you have access to a masters swim program?YesNoWhat is the most difficult part of swimming for you*What is a long swim for you*Have you ever swum with pace zones/times*Additional information about swimmingDo you have a bike trainer?Have you ever trained with power?Do you have a cycle computer with cadence function?Do you have access to a running track?YesNoDo you ever run with a group?How often do you change your running shoes (# months)How many times per week do you normally run?What do you consider to be a long run right now (hr:min:sec)Have you ever done any interval training?YesNoHow many years have you been running?Do you have a treadmill you can use?YesNoPreferred day off from trainingMondayTuesdayWednesdayThursdayFridaySaturdaySundayHow many kilometers or hours did you train in the past 12 months for each sport?SwimBikeRun What were the most important races you did in the last 12 months?Do you own a heart rate monitor?YesNoHow familiar are you with training with a heart rate monitor?Not at allSomewhatVeryExpertDo you own a Computrainer or other power meter device?YesNoWhat is the highest heart rate you have observed during exercise?In which sport?Do you know your lactate threshold for any sport?SwimBikeRun Limiters In order to focus your training most efficiently, we need to determine your limiters: those aspects of fitness that are limiting your current performances. Please take a few moments to assess your abilities on a score of 1-5. 1 = among the worst in my race category 3 = about the same as others in my race category 5 = among the best in my race categoryEnduranceEndurance: The ability to delay the onset and reduce the effects of fatigue, implies an aerobic level of conditioning.SwimBikeRun ForceForce is the ability to overcome resistance: how well you do in rough water, hills, or in the wind.SwimBikeRun Speed SkillsSpeed Skills is the ability to move effectively while swimming, biking, or running. A measure of economy and technique.SwimBikeRun Muscular EnduranceMuscular Endurance is the ability of the muscles to maintain a relatively high force load for a prolonged time. A combination of force and endurance.SwimBikeRun Anaerobic EnduranceAnaerobic Endurance is the ability to resist fatigue at very high efforts when arm or leg turnover is rapid.SwimBikeRun PowerPower is the ability to apply maximum force quickly.SwimBikeRun Diet & Miscellaneous FactorsTime to train:PoorGoodExcellentInjuries:PoorGoodExcellentHealth:PoorGoodExcellentBody Strength:PoorGoodExcellentFlexibility:PoorGoodExcellentMental Skills:PoorGoodExcellentBody Composition:PoorGoodExcellentNutrition:PoorGoodExcellentDiet: What did you eat yesterday?Phew! You're done! Thank you very much for providing so many details about yourself. Do you have any comments or questions before you submit this form? RELEASE OF INFORMATION AGREEMENT I, the signer of this document, in consideration of being coached in an endurance sport program by Healthy Results Personal Training, do hereby waive, release, and forever discharge Healthy Results Personal Training, and all employees and associates of Healthy Results Personal Training, including but not limited to Richard Pady, of all responsibility or liability from injuries or damage resulting from my participation in any activities or program. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of Healthy Results Personal Training. I understand and am aware that the program given to me from Healthy Results Personal Training, including the use of equipment, involves a risk of injury, and that I am voluntarily participating in the program and using my equipment with knowledge of the dangers involved. I here by agree to expressly assume and accept any and all risk of injury. I do hereby further declare myself to be physically sound and suffering from no medical condition, impairment, disease, infirmity, or illness that would prevent my participation in any physical exercise program. Nor am I prevented, for any reason, from the use of exercise equipment or machinery except as may be noted hereinafter. I do hereby acknowledge that I have consulted with my physician regarding my intention to participate in a Healthy Results Personal Training program. The only restrictions I have respecting my ability to participate in this program are as follows:State restrictions (if any)Type Full Name here:*This field entry confirms that you agree with all terms described in RELEASE OF INFORMATION AGREEMENT above.Date of signing this document:*
