Athlete Profile

Your Name (required)

Your Email (required)

Street Address (required)

City (required)

State (required)

Zip Code (required)

Cell Phone # (required)

Home Phone # (required)

Date of Birth (required)

Age (required)

Gender (required)

Height (required)

Weight (required)

Occupation

Hours

Married (required)

Children (required)

How did you hear about our coaching services?

Medical History

Primary Emergency Contact (required)

Phone Number (required)

Secondary Emergency Contact (required)

Phone Number (required)

Please list any medications, vitamins, supplements taken on a regular basis (dose and frequency)(required)

Are you allergic to any medications? (required)

If yes, please explain

Please list any current illness, recent injuries, recent surgeries, or past medical problems or surgeries of note.

Do you have, or have you had any of the following:
 Heart Disease Wheezing Heart Murmur Anemia Chronic Injury Asthma Heart Surgery Epilepsy Thyroid Problems Chronic Pain Heart Attack Diabetes Hypertension Stress Fracture

If female, is there any chance you could be pregnant? (required)

Do you Visit a chiropractor? (required)

Do you get Massages? (required)

Do you Stretch? (required)

Do you do Yoga? (required)

Are you currently recovering from any injury or illness? (required)

If yes, please explain

Any special medical needs or information the coach should be aware of? (required)

If yes, please explain

Equipment and Other Information

What equipment do you have, if any? (e.g. watch, pool toys, indoor trainer, etc.)(required)

Which day(s) would you like off, if any, each week (required)

Which day would you like your longest training to be scheduled (required)