EmailMe Form - BASE Tri Fitness New Athlete Questionnaire

Name *

First Last

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Email *

Age *

Birthdate *

Any medical illness (chronic or acute) I should be aware of OR any injury/illness that may be worsened by a change in physical activity? *

Work Information

Occupation *

Hours/Day *

Days/Week *

Working Hours (i.e. 8 am - 5 pm Monday-Friday) *

Are your working hours flexible? *

% Work Travel?

Do you have a gym at work

Are you able to workout during lunch hour?

If yes, what are you able to do?

Is there anything else I should know about your work schedule?

Diet and Hydration Habits

Do you follow a particular diet? (vegan, low carb, etc)

Do you consume caffeinated beverages?

If so, how many a day

How much water do you drink a day?

Do you take a daily vitamin or other supplements?

Training and Racing History

Please provide a summary of your athletic history in the past 10 years. *

Please note any major or recurring injuries and the years those injuries occurred

Have you used a coach or training plan in the past? (Please do not list a particular coach's name here)

What did you like/dislike about the program and/or coach *

List your MOST RECENT season's races and results. *

Do you strength train?

If yes, how many times/week?

Do you stretch regularly?

If yes, how many times a week

Do you use a power meter on your bike?

Do you have an indoor trainer or rollers for your bike?

Do you use a heart rate monitor on the bike or run? (list which sports)

Personal Best Times

Please list PR Time, DATE, and Race name

Open 5K Run

Open 10K Run

Open Half Marathon

Open Marathon

Sprint Triathlon

International Distance Triathlon

Half Ironman (70.3) Triathlon