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.
Home Phone______________________Work Phone_______________________________
Email Address_____________________Fax Number_____________________________
(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)
Pace or Time
_______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.
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)