Athlete Assessment

Personal Data

Your Name (First & Last required):

Your Email (required):

Your Phone:

Your Date of Birth (yyyy-mm-dd):

Height:

Weight:

Resting heart rate:

Gender:

MaleFemale

Foot & Ankle concerns for running (please check more than one if applicable):

PronationSupinationBunions (Hallus Valgus)Plantar FasciitisHigh Arches (Pes Cavus)Flat arches (Pes Planus)Ankle Sprain

Leg concerns for running (please check more than one if applicable):

Shin SplintsEdemaVaricose veinsAchilles Tendonitis

Knee issues for running (please check more than one if applicable):

Osgoode SchlatersMCL TearACL TearArthritisTendonopathy

Please remember I'm a running coach and not a doctor and I really want you to go to a medical professional if you have any of these issues. Your long term health is my primary concern. If you are new to running always see your doctor to assess your fitness for running.

Current Running Data

How many KM a week do you currently run?

How many years have you been running?

What time of day do you like to run?

I enjoy this type of running most:

TrailRoadSpeed (track)

Do you own a treadmill?:

YesNo

Do you do strength training?:

YesNo

Do you do cross training?:

YesNo

Do you own a GPS or phone with Strava?

YesNo

Your Personal Best Times:

1 KM
5 KM
10 KM
16 KM (10 miles)
21.1 KM (Half Marathon)

42.2 KM (Half Marathon)
50 KM (Trail Ultra)
80 KM (50 Mile Trail Ultra)
100 KM (Trail Ultra)
100 Mile (Trail Ultra)

Future Running Goals

Your future running goals are what this exercise is all about! Please answer these questions to help me better understand what you want to achieve. If you need more room to write you can drag the bottom right corner of the text window to expand.

Reasons for Running - please write all the reasons you have run over the course of your life:

Your Runners High - please write about one or more of the peak most enjoyable experiences that running has brought to you:

Your Lowest Low - lets face it everything has lows and highs including running. Tell me about your worst running experience:

Your Running Ideal Place - now tell me what you hope to get out of running in the future! What are your overall life goals?:

Your Heros - They don't need to be runners. Help me understand you by the hero you hold in high regard:

Your Goal Races or Events - please list the races you want to run and what your goal times are:

Talk to me about weight - fat weighs less than muscle and everyone is built differently. Let me know if you have ever struggled or feel you are struggling with weight. I want to help you be comfortable with a suitable weight and less concerned about it and more concerned with measurements, lean muscle mass and "right sizing":

Are you ready for physical activity?
Regular physical activity is fun and healthy, and increasingly more people are starting to become more active every day. Being more active is very safe for most people. However, some people should check with their doctor before they start becoming much more physically active.

If you are planning to become much more physically active than you are now, start by answering the seven questions in the box below. If you are between the ages of 15 and 69, this will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not used to being very active, check with your doctor.
Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO.

YesNo 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?

YesNo 2. Do you feel pain in your chest when you do physical activity?

YesNo 3. In the past month, have you had chest pain when you were not doing physical activity?

YesNo 4. Do you lose your balance because of dizziness or do you ever lose consciousness?

YesNo 5. Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?

YesNo 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?

YesNo 7. Do you know of any other reason why you should not do physical activity?

Waiver

Nick Brindisi (coach at Instil Coaching)

16 Trafalgar Rd.
Collingwood, Ontario
L9Y 5G4
(705) 994-3630

WAIVER AND RELEASE FROM LIABILITY

I, acknowledge that any fitness activities associated with the Instil Coaching running program(s) may be an extreme test of my physical and/or mental abilities. I hereby certify that I am fit to participate in any and all such activities and that such determination has been made by a qualified medical professional.
I acknowledge further that any and all such activities carry with them the potential from harm – both to myself and to my property, including but not limited to loss of or damage to my possessions, bodily injury and death.
I hereby certify that I understand and accept all risks associated with my participation in the Instil Coaching running program(s) and I agree to hold harmless Nick Brindisi, staff, volunteers, any and all associated person(s) and/or entities from and against any and all liability for any harm to myself or to my property that may arise from my participation in their running and all other related fitness programs.

Instill Coaching Policies

- All Instill Coaching participants must be aware of their respective physical condition levels and limits. They must understand that there are risks associated with their participation in the Instill Coaching fitness program(s).

- The scheduling and or content of training workouts/fitness classes may be changed on occasion due to circumstances beyond the control of Instill Coaching training staff.

- Instill Coaching membership payments are non-refundable.

I have read and fully understand the above waiver and release from liability & policies, and I agree to abide by the terms and conditions set forth therein.

Checking this box indicates acceptance of the above WAIVER AND RELEASE FROM LIABILITY: