Coaching Questionnaire

In order to help plan a fitness/athletic program for you, it is necessary to evaluate some of your health and lifestyle history – as well as your present running fitness.

Please answer to the best of your ability. Your information will be kept confidential and used only in helping make recommendations for a fitness program.

Your Full Name (required):

Today's Date:

Your Email (required):

Your Age:

Sex: MaleFemale



Mailing Address:

Best Contact Phone Number:

Current State of Health:


Are you currently injured or recovering from an injury?: YesNo
If so, what is the injury?
Date of onset?

Previous running injuries:

How long have you been running?

Have you been diagnosed as having any of the following:
Cancer*Heart ProblemsHepatitisHigh Blood PressureAsthmaStrokeAnemiaThyroid ProblemsDiabetesAllergiesRheumatoid ArthritisOther ArthritisEating DisordersDepressionNone of the above

*If you marked "cancer", please specify what kind:

Running Interest (check all that apply):
Fitness and FunRecreation or Social RacingRacing for Improved Performance

What is the best day of the week for your long run:

Preferred day off:

How many hours and days per week can you allow for training:
Days per week:

How long have you been running:

How many days per week do you run now:

Current weekly mileage:
Current longest run:

Longest race you have run:

Do you wear orthotics: YesNo

Do you run year round: YesNo
If not, how many months?

How much water do you drink each day:

How many hours do you sleep each night:

What is your goal for lifetime running:

What do you hope to get our of your coaching program:

What running goals do you have for:
Next 3 months:
Next 6 months:
Next 12 months:

Marital Status:

Children at home:


What is your weekly work schedule:

Additional Comments or Information:


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©2017 Judy Mick. All Rights Reserved. Site by Diabla Design