Athlete InformationPlease provide as much information as you can. Name * First Name Last Name Email * Phone DOB Medical History Have you ever had any of the following? Diabetes Yes No Hepatitis Yes No Pneumonia Yes No High Blood Pressure Yes No Back/Joint pain Yes No Kidney Infection Yes No Heart Mumor Yes No Heart Disease Yes No Head Injury Yes No Angina/Chest Pain Yes No Are you suffering from a heart condition Yes No Do you feel pain in the chest when performing physical activity Yes No Do you suffer from back or joint problem that could be made worse through physical activity Yes No Do you suffer from high or low blood pressure Yes No Are you taking medication to control your blood pressure or a heart condition Yes No Do you suffer from respiratory illness (asthma, bronchitis, emphysema) or have shortness of breath with mild exertion Yes No Are you under medical treatment for any illness Yes No Have you recently had surgery Are you on any regular medications? Do you have any allergies? Do you have any injuries? Lifestyle Availability for Run training Monday Tuesday Wednesday Thursday Friday Saturday Sunday Training History, Equipment and Training Environment 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. Thank you!
