Get Started

Please fill out the following form as accurately as possible. If you have any questions at all please feel free to contact me by phone (610) 873-7355. I also ask that you fill sign the following waiver before getting started. After I have received the form below, I am usually prompted with more questions for you and will call you to further get to know you. When I am satisfied that I have all of the information that I need to get started with your training plan, I will confirm a start date with you.  (Note: *=required field)

BASIC
Name *
Address *
City *
State *
Zip Code *
Country *
E-Mail *
Home Phone *
Work Phone *
Fax
Cell Phone
Gender *
Birthdate *

COMPUTER
Operating System
Email Application
Word Processing Application
Spreadsheet Application

PERSONAL
Occupation
Hours Per Week
Stress Level
Marital Status
How Many Children?
Their Ages?

ATHLETIC
Years Training?
Which Sports?
Years Competing?
Which Sports?
Best Races, Times?
Any other accomplishments you would like me to know about?

CURRENT FITNESS

Rate your current fitness (1=worst shape, 10=best shape)?

Do you know your maximum heart rate, lactate threshold, VO2 Max, etc?

MAX HR VO2 MAX LT THR
BIKE
RUN

Do you know the above from Stress Test, Race, Lactate Test, etc.? Select all that apply.

If you train with a heart rate monitor, which make/model do you use?

If you train with a power measuring device for cycling, which make/model do you use?

PHYSICAL PROFILE

Check all that apply to you

MENTAL PROFILE

Do you consider yourself to be (please check one):
 highly motivated fairly motivated not motivated

Do you consider yourself to be (please check one):
 very confident fairly confident lacking confidence

Do you believe you have the ability to be (please check one):
 very focused fairly focused not focused at all

Assign the appropriate number to each of the statements below.
1=Rarely 2=Occasionally 3=Often 4=Always

I believe I have great potential as an athlete.
I believe I am very successful at the things I put my mind to.
I can race close to or above my ability level.
I am mentally tough.
I don't lose my confidence after I have a bad race.
I love to train and rarely miss a planned workout.
I am fired up on the morning of a race.
I am willing to make sacrifices to achieve my goals.
I set very high goals for myself.
I try to be the best I can possibly be.
I stay positive even when things go wrong.
I am positive and pumped up before races.
I learn from all of my races - good and bad.
The harder the race the better.
I can relax before races.
I have no self-doubts before races.
I have no problem staying focused during races.
I can block out distractions during races.
I concentrate best when the race gets hard.
I can imagine myself doing well in the hardest races
I can visualize handling tough race situations.
I mentally rehearse strategy, skills and possible race scenarios before races.
I can visualize doing well in the big races

Please list your greatest strengths (mental and/or physical):

Please list your greatest weaknesses (mental and/or physical):

MEDICAL INFORMATION

Weight (lbs)

Ideal Weight (lbs)

Height (inches)

% Body Fat

Are you currently under the care of a physician?  Yes No
If yes, please explain

Are you taking any medication?  Yes No
If yes, please list
Do you smoke? (please check all that apply)
 Yes No Have you had complete physical in the last year?
 Yes No Have you or anyone in your family had coronary artery disease?
 Yes No Have you ever fainted or felt dizzy after exercise?
 Yes No Has a doctor said that your blood pressure is too high?
 Yes No Do you have heart trouble, a heart murrmur or have you had a heart attack?
 Yes No Do you ever have chest, shoulder, neck or arm pains during exercise?
 Yes No Are you diabetic, have a thyroid or any other chronic condition?
 Yes No Is your cholesterol level high?
 Yes No Are you now or have you been pregnant during the last three months?
 Yes No Do you have any conditions that your doctor says may limit your physical activity?
 Yes No Do you have any conditions that you think may limit your physical activity?

Please consult your physician before starting this or any exercise or training program.

YOUR CURRENT SCHEDULE

How much time (hr:min) do you have available to train?

Mon
Tue
Wed
Thr
Fri
Sat
Sun

Enter Total available for an average week:

What time do you need to be done training in the morning to get to work on time?
What time do you get home from work?
What time do you typically go to sleep at night?

What is your longest training session during the past month?

Time Distance
SWIM
BIKE
RUN

Over the past two months what is the average number hours/week you trained?

Hours/Week
SWIM
BIKE
RUN
STRENGTH
Other

Can you vary your training time? Or do need to train the same hours each week? (Explain)

Are there any regular group workouts that you participate in? If so, please list and describe the workouts as accurately as you can (I.e.,time, intensity, time of day, sport, how many people,)

When and where can you swim?

Please give an idea of your typical training week, include AM, PM, Times, workout detail, etc.

MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY

I want to get started!

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