Email

Phone

DOB

Medical History

Have you ever had any of the following?

Diabetes

Hepatitis

Pneumonia

High Blood Pressure

Back/Joint pain

Kidney Infection

Heart Mumor

Heart Disease

Head Injury

Angina/Chest Pain

Are you suffering from a heart condition

Do you feel pain in the chest when performing physical activity

Do you suffer from back or joint problem that could be made worse through physical activity

Do you suffer from high or low blood pressure

Are you taking medication to control your blood pressure or a heart condition

Do you suffer from respiratory illness (asthma, bronchitis, emphysema) or have shortness of breath with mild exertion

Are you under medical treatment for any illness

Have you recently had surgery

Are you on any regular medications?

Do you have any allergies?

Do you have any injuries?

Lifestyle

Training History, Equipment and Training Environment

Swim

Please provide details on your current swim training (frequency of training each week, km total per week) and what you have available for training - eg pool 50m, squad, open water

Bike

Please provide details of your current training (frequency of training each week, km total per week) and what you have available for training - eg power, trainer, HR

Run

Please provide details of your current run training (frequency of training each week, km total per week) and what you have available for training - eg access to athletics track, trails...

Results

Race Results

Please provide any race results. Please include distances, times and dates.

Planned Races

Please provide your planned races. Dates, distances and importance (A,B,C where A is the most important)

Any Further Information

Please provide any information you believe this form has not covered and you would like Emma to know.

Athlete Information

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