Fill out this form as completely as possible & print and sign the release form on the final page. Mail your check to
191 Crossing Dr. Stockbridge, GA 30281, or make your payment online at
http://www.runningstrong.com/payments.html . Send the completed form to janet@runningstrong.com
We still need a printed copy of the release form with a signature, but we can initiate the coaching process with an
e-mail version of this questionnaire. If you are being evaluated in person, payment can be made at that time.
Please click the appropriate field and enter your response. If you experience difficulty with this form, email
janet@runningstrong.com for assistance. When you have completed the form, save it as YourName.doc and send it in an
email attachment to coach Janet. You will be contacted to set up an appointment for your initial consultation.
Personal Information
Name
Age:
Date:
Sex
Address:
City:
Height
Weight
Resting HR_
_
__ State:
Home phone:
E-Mail address:_
_ Zip
_ Work Phone:
_
_ Cell Phone:
_
Personal Medical/Running Information:
Medications: (Please list all over the counter as well as prescription medications that you currently take):
Have you ever been diagnosed as having any of the following conditions?
Cancer (please specify what kind)
Heart Problems
Hepatitis
High Blood Pressure
Asthma
Stroke or Transient Ischemic Attack
Anemia
Thyroid Problems
Diabetes
Allergies
Rheumatoid Arthritis
Other Arthritis (osteoarthritis, ankylosing spondylitis, etc)
Disordered Eating (under-fueling, excessive exercise, bingeing, calorie restricting, etc)
Eating Disorder (Anorexia / Bulimia)
Depression
Other - (please be specific)
Health Risks: Has anyone in your immediate family (parents, brothers, sisters) ever been treated for the following?
Check all that apply.
Diabetes
Heart Disease
High Blood Pressure
Stroke or Transient Ischemic Attack
Cancer
Anemia
Arthritis
Current condition that leads you to seek professional coaching. Are you currently injured or recovering from an
injury?
Injury (diagnosis if you know it):
Date of onset:
Previous treatment regime (physical therapy? massage? ice/heat? etc.)
Previous Running Injuries: include dates
How long have you been running?_
Previous exercise or competitive history:
Racing Experience: None
Beginner
Experienced
Recent Race Performance in last 6 months:
5K
10K
other distance (specify
half marathon
marathon
Personal Bests (list your best performances)
Distance
Pace or Time
Distance
Pace or Time
Distance
Pace or Time
Date
Date
Date
Running Interests check all that apply:
Fitness or fun
Recreational or social racing
Racing for improved performance
Racing for age group or other awards
List your running and racing goals. Include future dates, distances, time goals, etc.
Describe any previous problems you've had with racing or training.
Do you perform flexibility exercises on a regular basis? If so, please list or briefly describe them below:
Do you perform strength exercises on a regular basis? If so, please list or briefly describe them below:
Shoes
Manufacturer:
Model:
Age:
Recent Training
Describe your most recent 2-4 weeks of training in detail. List the miles or time spent running, your pace or heart rate,
the surface or terrain (track, hills, trails, bark chip path, etc) and any supplemental or additional training (weights, Yoga,
cycling, swimming, etc).
Example:
4 mi
34:00
rolling hills
20 min weights
Mon
Tues
Wed
Thur
Fri
Sat
Sun
Last
Week
2 wks
ago
3 wks
ago
4 wks
ago
Prior Experience with Team or Individual Coaching: Please describe any previous experience you
have had with a coach or trainer, either in a team training environment or as a personal coach, and
describe any particular positive or negative aspects of that experience:
Expectations from Coaching: Please describe what it is that motivated you to seek the assistance of a
coach at this time, and what you hope and expect to achieve with the help of a coach:
Additional Comments or Concerns:
In order to help us plan a rehabilitation and training program for you, it is necessary to evaluate some of
your health and lifestyle history as well as your present state of fitness. The questions need to be
answered to the best of your ability. The information gathered will be used only in making
recommendations for your training program and is not shared with any other person or entity. Your
individual information is kept strictly confidential.
The coaching guidance provided by Running Strong is not intended in any way to substitute for
professional medical advice. Always seek the guidance of your physician or other qualified
health provider with any questions you have regarding a medical condition. Neither the
content nor any other service offered by or through Running Strong is intended to be relied on
for medical diagnosis or treatment. Never disregard medical advice or delay in seeking it
because of something you have read on this or any other web site!
Consent & Release:
Please print out the Waiver and Release form on the next page, initial and sign where indicated and mail it to
Running Strong
191 Crossing Dr
Stockbridge, GA 30281.
Running Strong* 191 Crossing Dr* Stockbridge, GA * 30281
Contact coach Janet Hamilton at Phone/Fax: (770) 957-0986 Or 678-357-6406
Participant’s Name_
_______ Age __
_____
Waiver of Liability, Assumption of Risk, and Indemnity Agreement
Waiver: In consideration of being permitted to participate in Janet Hamilton’s Training Program through
Running Strong I, for myself, my heirs, personal representatives and assigns, do hereby release, waive,
covenant not to sue and discharge Janet Hamilton, and Running Strong from liability from any and all claims
including the negligence of Janet Hamilton resulting in personal injury, accidents or illnesses (including death),
and property loss arising from, but not limited to, participation in a running, walking, cycling, swimming or
multisport training program.
_____________
Signature
____
Date
Assumption of Risks: Participation in physical activity and conditioning programs carries with it certain
inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I know that exercise is a
potentially hazardous activity and certify that I am in good health and physically fit to enter into a general
conditioning program. I acknowledge that I am aware of the many risks involved in various forms of exercise in
general and walking or running training specifically, which risks include by way of example and not limitation:
1) minor injuries such as scrapes, bruises, sprains and strains, 2) more serious injuries such as joint, muscle and
bone injuries, concussions and other head injuries, heat related injuries such as heat stroke and heat exhaustion,
dehydration and over hydration conditions such as hyponatremia, and catastrophic injuries and conditions such
as heart attacks and other conditions or injuries which could be fatal. I have read the previous paragraphs and I
know, understand, and appreciate these and other risks that are inherent in exercising and training for general
conditioning and health improvement. I hereby assert that my participation is voluntary and that I knowingly
assume all such risks.
_
_________(Initial)
Indemnification and Hold Harmless: I also agree to INDEMNIFY AND HOLD HARMLESS Janet Hamilton
and Running Strong from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities,
including attorney’s fees brought as a result of my involvement in Janet Hamilton’s Training Program
__
__(Initial)
Severability: The undersigned further expressly agrees that the foregoing waiver and assumption of risks
agreement is intended to be as broad and inclusive as is permitted by the law of the State of Georgia and that if
any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal
force and effect.
Acknowledgment of Understanding: I have read this waiver of liability, assumption of risk, and indemnity
agreement, fully understand its terms, and I understand that I am giving up substantial rights, including my right
to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be a
complete and unconditional release of all liability to the greatest extent allowed by law.
_
___________________
__________
Signature
Date