Coach Amy Athletes: Coaching

Questionnaire
In order for me to plan a fitness/athletic 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 information will be kept confidential.
Name______________________________________________________Date____________________
__
Age________________________________Sex_____________________________________________
__
Address_____________________________________________________________________________
_
City___________________________________State_________Zip____________________________
___
Home Phone_______________________________Other
(Work/Cell)_____________________________
Email Address______________________________
Height____________________________________Weight___________________________________
___
If You Know:
% Body Fat__________________Resting Heart Rate__________________Maximum Heart
Rate_______
Medications_________________________________________________________________________
__
Current State of
Health__________________________________________________________________
If currently sick or injured, describe difficulty and date of
onset__________________________________
_____________________________________________________________________________________

Health Risks (i.e., past injuries, family history, chronic disease,

etc.)______________________________
_____________________________________________________________________________________
How long have you been running?
_________________________________________________________
Previous exercise and/or athletic
history____________________________________________________
_____________________________________________________________________________________

Racing Experience
None_____________Beginner__________________Experienced___________________________
_____
Current Racing (list all races in last 6 months)
Distance

Pace or Time

Date

Pace or Time

Date

Personal Bests
Distance

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, and goal times)
_____________________________________________________________________________________
_____________________________________________________________________________________

Describe any previous problems with racing or training

_____________________________________________________________________________________
_____________________________________________________________________________________
Why are you seeking personal coaching?
_____________________________________________________________________________________
_____________________________________________________________________________________

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,
hilly, etc.), and any supplemental or additional training (weights, stretching, other
aerobic activities, etc.)
Example
3 miles at 10:00 min pace
Flat country road
Biked with the kids for 30 minutes
Sun
Last Week
2

Mon

Tues

Wed

Thu

Fri

Sat

Additional comments or concerns

Thank you for taking the time to complete this survey. I look forward to helping
you meet your goals!

Adapted from Team Oregon Coaching Questionnaire