Athlete Health Discovery Form Step 1 of 5 20% Personal InformationFirst Name*Last Name*Date (dd/mm/yyyy)* Date Format: DD slash MM slash YYYY Email Address* Phone*Time Zone?*City, State*Height*Birthdate*Age*Current Weight*Would you like your weight to be different? If so, what?*Who invited you to the Assessment?*Coach BKCoach BeckyCoach ElisabethCoach GinaNewsletterPodcastSocial InformationRelationship StatusSingleMarriedDivorcedWidowedUnder 18Where do you currently live?*OccupationChildren - Ages (names optional)ChildhoodHappyAverageChallengingPersonality*Type A: In charge and in controlType B: Outgoing and energeticType C: Detailed and logicalType D: Easy going and hard workerIntrovertExtrovert Health InformationPlease list your main health concerns:*Number of days you work out each week:*Any serious illnesses/hospitalizations/injuries?*How is your sleep?*Hour many hours on average do you sleep at night?*Less than 44 - 56 - 78+Does a busy mind affect your sleep?*YesNoWorking on controlling thisDo you wake up feeling rested?*How do you deal with stress?Over eatSmokeDrink alcoholExerciseJournal feelingsTalk about the stress with a friend/otherWatch tvBottle up feelingsGet irritatedPrayDo you burp after meals? Even small burps?*Do you have weak or brittle nails?*What is your fasting blood glucose if you know or have access to it?What is your blood pressure? (if you have access to it or can get it tested.) Women's HealthAre your periods regular? ( or n/a)Acne in the past? Now?Do you have PMS, painful periods or other symptons? Other details (or n/a):*Birth control history (or n/a):* Athlete SpecificBriefly Describe athletic backgroundWhere do you play?RunBikeSwimGym / CardioGym / WeightsWhat are your average paces? Swim/bike/run?How do you FUEL yourself on the swim/bike/run?Would you say that you sweat a lot? (yes, no, comment)*CrampingDescribe any cramping that you get. Calves? Swimming? Bike?Do you experience restless legs?Describe: nightly, just when it is hot, etc.What EQUIPMENT do you have. Heart rate monitor Garmin Something (910,920,...) Other heart rate monitor Bike Trainer Smart Bike trainer Upload to Garmin Connect Use Zwift Power Meter Wetsuit Do you do yoga?YesNoIn the pastDo you know your heart rate zones? What are they?Athletic Goals? Race Date? Time Goals?What shoes do you run in? Brand, neutral, stability, drop?Shoe sizeShirt SizeAnything that you'd like to see different with your athletic performance?During last race or training cycle, anything that you would like to see different?Injury History / when have they occurred.Any obstacles or life commitments that could interfere with your training.How many hours a week can you train? Idea on best days and times? Food / Dietary / Health InformationWhat supplements / protein mix / MEDICATIONS are you eating?Foodie Type*Eat MeatVegetarianVeganHow many grams of protein per day are you eating? If you know.*How many calories per day are you eating? Rough idea.*What is the worst thing that you eat?*Do you crave sugar, coffee, cigarettes or other things?*Are you involved in holistic therapies (chiro, acupuncture, therapist, etc) (or n/a):*Conclusion and finishing upWhat is the most important thing you can do to improve your health?*Do you currently have a coach? Triathlon Coach Run Coach Health Coach No, zero coach Yes, but I am not happy. Anything else you would like to share?PhoneThis field is for validation purposes and should be left unchanged. Δ 2016-04-06 Coach BK
