Athlete Questionnaire

Contact Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone*
Emergency Contact*
Emergency Contact Phone*
Please upload a headshot*
File size cannot exceed 2MB (jpg, gif and png accepted)
Accepted file types: jpg, gif, png, Max. file size: 2 MB.

Medical History
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Height (in inches)*
Please enter a number from 50 to 85.
Weight (lbs)*
Please enter a number from 90 to 400.
Is this your normal weight?*
- Yes
- No
Resting HR if known
Please enter a number from 25 to 100.
Conditions/Chronic Diseases*
Do you have or have you ever had any of the following? Select all that apply. Hold SHIFT to click on multiple selections.
If other, describe here:

Psychological
In the boxes below, rate yourself on a scale of 1-5 on the following:

1=Poor | 2=Fair | 3=Good | 4=Very Good | 5=Excellent
Self-awareness*
Level of confidence to complete the "A" race*
Ability to set goals and target*
Ability to follow through with goals*
Use of visualization/imagery to prepare for a race*
Use of self-talk/thought control*
Ability to pay attention/focus under stress*
Ability to endure peak sensation*
Ability to excel under pressure*
Ability to make decisions under stress*
Ability to be consistent*
Ability to take recovery days without guilt*

Strength and Conditioning
Describe your current strength and conditioning program*
Which of the following types of equipment do you have access to?*
Select all that apply. Hold SHIFT to click on multiple selections.
Does your occupation require extended periods of sitting?*
- Yes
- No
Does your occupation require extended periods of repetitive movements?*
- Yes
- No
If yes, please explain

Contact Information