Athlete Health History Questionnaire

Athlete Health History Questionnaire

Please fill out our Athlete Health History Questionnaire below so we can better understand your current health status. It is in the best interest of any athlete looking to enroll in an ultrarunning coaching program or registering for an ultramarathon race to be cleared by their physician within the last 12 months. It is also advised for any athlete to have a cardiac assessment (EKG stress test) within one year prior to registering for an ultrarunning coaching program or ultramarathon race.

Name

First Name

Last Name

Phone

(###)

###

####

DOB

Date Of Birth

YYYY

Gender

Gender Identification

Weight

What is your current weight?

Height

What is your current height?

Heart Rate

What is your resting heart rate upon waking?

Drugs & Medications

Do you take any drugs or medications?

Heart Desease

Is there any family history of heart disease?

Physical Examine

What was the date of your last medical physical examination and is there anything we should be aware of from this visit?

Emphysema

Do you have emphysema?

Pregnant

Are you, or have you been recently pregnant?

Cholesterol

Do you have high cholesterol?

Cholesterol Continued

If you answered yes above, are you under care of a physician for your cholesterol?

Surgery

Have you had any surgeriers in the past year?

Surgery Continued

If you answered yes above, please list the surgery you had and date when the procedure was performed. If this is too personal, please enter "too personal".

Injury

Have you ever had an injury that caused you to stop exercising for more than a week? If so, please explain.

Anorexia & Bulimia

Are you, or have you ever been, anorexic or bulimic? If so, please list which one.

Physical & Emotional Problems

Are there any other physical or emotional problems that could affect your training? If so, please list here.

Alcohol Consumption

Do you drink alcohol? If so, how much per week?

Metabolic Diseases

Do you have any metabolic diseases such as diabetes, hyperthyroidism, etc.? If so, please list here.

Smoking

Do you, or have you ever, smoked regularly?

Smoking Continued

If you answered yes above, please give us a brief history of how much you've smoked in the past.

Medical Conditions

Do you currently or have you had any of the following conditions:

Medical Conditions Continued

If you have any other medical condition(s) than what was listed above, please enter them here. Additionally, if you had more than one medical condition above, list it here. If you did not have any of the medical conditions listed, enter NA.

Additional Message(s)

Please let us know if there is anything else you believe we should be aware of or if you have any additional questions you'd like to have us answer.

Guided Trail Running Trips Ultrarunning Coaching Eastern Sierra Mammoth Lakes Yosemite National Park