Team Oregon / Running Strong Rehab Coaching Questionnaire


Print this form, fill out, sign the release at the bottom and return it with your check to Running Strong c/o Janet Hamilton 191 Crossing Dr. Stockbridge, GA 30281. The fee for the first month of "virtual" coaching (including the initial consultation)  is $100.  Subsequent months are $85. Discounts may be given when signing up for multiple months (contact Janet Hamilton for details).  See description of fees on the REHABILITATION  web page. Checks payable to Running Strong.

For fast response, you can fax  the completed form or paste the form into your mail program, fill it out and email it to us. We will still need a printed copy with a signature sent along with your check.



Running Strong
191 Crossing Dr.
Stockbridge, GA.  30281
email:
phone/fax:   (770)-957-0986 (Running Strong / Team Oregon Rehab coaching)

Personal History

Name__________________________________________________Date_______________

Age______________________________Sex_____________________________________

Address__________________________________________________________________

City________________________________State___________________Zip__________

Home Phone______________________Work Phone_______________________________

Email Address_____________________Fax Number_____________________________

Height____________________________Weight_________________________________

(If you know)
% Body Fat___________Resting Heart Rate (HR)__________Maximum HR_________

Personal Medical/ Running History

Medications (please list all over the counter medications as well as prescription medications that you currently take)
________________________________________________________________________

________________________________________________________________________

Current State of General Health__________________________________________________

Have you ever been diagnosed as having any of the following conditions?

Health Risks:  Has anyone in your immediate family (parents, brothers, sisters) ever been treated
for any of the following?

Current condition that leads you to seek Rehab coaching. Be specific as to injury onset date, type,
previous treatment regime, etc. The more information you give us, the better we can help you.
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Recent Previous Running Injuries, including date______________________________________

__________________________________________________________________________

__________________________________________________________________________

How long have you been running?__________________________________________

Previous exercise or competitive history_____________________________________________

___________________________________________________________________________

___________________________________________________________________________
 

Racing Experience  None______Beginner_____________Experienced____________

Current Racing ( List races in last 6 months)

Distance                        Pace or Time            Date

Personal Bests  (List your best performances)

Distance                        Pace or Time            Date
 
 
 
 

Running Interests
_______Fitness and Fun
_______Recreational or Social Racing
_______Racing for Improved Performance
_______Racing for Age Group or Other Awards

List  your running and racing goals(future races, dates & goal times)

_________________________________________________________________________

_________________________________________________________________________

Describe any previous problems with racing or training___________________

_________________________________________________________________________

_________________________________________________________________________

Describe your most recent 4 -6 weeks of training in detail. List the miles or time spent running, your pace or heart rate, the surface or terrain (track, road, bike path, bark chips, trails, flat, hilly, rolling etc.)and any supplemental or additional training (weights, stretching, cycling. swimming, aerobics etc.) Include any races run.

Example 

4 mi @ 8:30 pace
rolling road
stretching
20 min weights


Sun        Mon       Tue       Wed       Thu       Fri       Sat
Last
Week





2





3





4





5





6




Additional comments or concerns__________________________________________

_________________________________________________________________________

_________________________________________________________________________ 

Running Strong / Team Oregon Rehab coaching

In order to help us plan a rehabilitation fitness program for you, it is necessary to evaluate some of your health and lifestyle history and practices 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 program. Your individual data will be kept confidential.

CONSENT AND RELEASE

I desire to participate in this program. I understand the risks involved in running, walking or other fitness activities and assume personal responsibility for my health and safety while participating in this program.

THE COACHING GUIDANCE GIVEN BY RUNNING STRONG AND THE TEAM OREGON REHAB COACHES IS NOT INTENDED IN ANY WAY TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH PROVIDER WITH ANY QUESTIONS YOU MAY HAVE REGARDING A MEDICAL CONDITION. NEITHER THE CONTENT NOR ANY OTHER SERVICE OFFERED BY OR THROUGH RUNNING STRONG, TEAM OREGON OR THE TEAM OREGON SITE 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 THE TEAM OREGON SITE!
 
 

_____________        ___________________________________________ 

Date                            Participant's Signature
                          (Parent or Guardian if Under 18)


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