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Athlete Intake Form

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Athlete Intake Form

Athlete Intake Form

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Your Name
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Emergency Contact Information
First Last
Phone
Best time of day to contact
Best way to communicate
- Email
- Text
- Phone
Birthdate
Age (years)
Waking Heart Rate (bpm)
Weight (lb)
Height (IN)
Gender
- Male
- Female
Occupation
Typical work week (hours)

Health History
Please explain in detail any “yes” answer. Will it change your ability to train or compete?
Have you or anyone in your family had coronary artery disease?
Do you ever have chest, shoulder, neck, or arm pains after exercise?
Have you ever fainted, felt dizzy, or unusually winded during exercise?
Has a doctor said that your blood pressure is too high or uncontrolled?
Has a doctor ever said you have heart trouble, a heart murmur, or have you had a heart attack?
Are you diabetic, have a thyroid condition, or any chronic condition?
Are you using any medications?
Is your cholesterol level high? If so, what’s your cholesterol count?
Have you ever had a complete physical exam including stress test on a treadmill or ergometer? If so, when?
Do you have any condition/injury that a doctor says may limit your exercise?
Have you ever smoked? When did you quit?
Have you ever had a joint or back disorder or any current injury?
Have you had surgery in the last 12 months?
Are you now, or have you been pregnant in the last 12 months?
Have you ever had a knee injury or knee surgery? When?
Have you broken a bone in the last 12 months?

Athletic Information
Strength training
- Nautilus
- Universal Gym
- Free weights
- Yoga
- Pilates
- None
Briefly describe your current strength and/or flexibility training routine (days per week, exercises/machines, sets, reps and resistance:
What shoes do you train and or race in?

History
Have you ever had a sport-related injury that caused you to stop exercising for a week or more? If yes, please describe.
Describe your athletic strengths
Describe your athletic weaknesses
List your best running cycling and/or triathlon results: Event/distance/ Year of Result
How long have you been running, cycling, and/or racing triathlon?

Current Training Information
What are your three most important long-term goals for athletics? Please rank them in order of importance:
What are your midrange goals for 3-5 years from now?
What are your life-style goals?
What are your 12-month goals?
What races/events are you planning for your upcoming season? Please give them A, B, or D priority.
At the completion of our first season together, how will we know if we were successful? What is the single most important first year goal we must accomplish?
Describe your typical training week?
Is the above week, _____ for you?
- High
- Low
- Average
What is the longest workout you have completed in the last 3 weeks? Duration:_____________ Distance: _____________Type______________
How many hours do you have weekly available to train?
Please note how much time you have available for training each day during a normal week by day?
Which day is best for you to take off from training?
How many miles and hours did you train in the past 12 months?

Miscellaneous Training Information
Do you own a heart rate monitor? If so, Brand and Model.
Do you own a power meter (if cycling)? If so Brand and Model.
How do you keep track of your training?
New Age Athlete utilizes Training Peaks. Do you already have a Training Peaks account?
- Yes
- No
What is the highest heart rate you’ve ever achieved during exercise?
Do you know your lactate and/or anaerobic threshold heart rate or power level?
What type of test did you undertake to determine it and when?
What type of cross training activity(s) are you willing to participate in?

Nutrition
What do you eat during a normal weekday? Breakfast, Lunch, Dinner, Snacks, Beverages including H2O intake
Calorie intake during training?
Calorie intake during racing?
Do you ever have stomach issues during training/racing? If so, please describe.
What are your key nutrition goals for this year?

Proficiencies Profile
Please either Agree or Disagree in response to each question. Elaborate if necessary. For questions relevant to cycling leave blank if that is not one of your disciplines.
I’m quite lean compared with others in my age group and category.
I’m more muscular and have greater total body strength than most others in my age group and category?
I’m usually capable of single-handedly bridging gaps that take several minutes.
I’m capable of enduring relentless suffering for long periods of time, perhaps even up to one hour.
I can sustain energy up long hills.
I am agile and technically advanced (cycling or trail running).
I have a high cadence (running 180 rpms and cycling over 110rpms).
I look forward to the climbs in races and hard workouts.
I have fast twitch muscle fibers based on my ability to accelerate quickly, sprint, etc.
While I suffer, I never “blow up” on climbs, even when the speed increases.
In a race, I can sustain lactate threshold for long periods of time.
During a race I can recover very quickly from maximal and near maximal efforts at, and above my lactate threshold.
In field sprint, I feel aggressive and mentally capable of winning (cycling).
When on a climb, I feel light and nimble.
I perform well under stress.

Natural Abilities
I prefer to ride in a bigger gear at a lower cadence (cycling).
- Yes
- No
My best results have come in short races. Please specify favorite distances.
- Yes
- No
I’m stronger at the end of long workouts than my training partners.
- Yes
- No
I can squat and leg press more weight than most others.
- Yes
- No
I perform better in longer races (distance).
- Yes
- No
I use longer crank arms than most others my height (cycling).
- Yes
- No
I get stronger as a long or multiday race or high volume training week progresses.
- Yes
- No
I comfortably use smaller gears with higher cadences than most of my regular training partners (cycling)
- Yes
- No
I have always been physically quicker than most other people for any sport in which I have participated.
- Yes
- No
In most sports, I’ve been able to finish stronger than most others.
- Yes
- No
I’ve always been physically stronger than most others I’ve played sports with.
- Yes
- No
I climb best when seated on the bike.
- Yes
- No
I prefer workouts that are short but fast.
- Yes
- No
I’m confident in my endurance at the start of long races.
- Yes
- No
I can ride into head winds alone easily.
- Yes
- No
When I’m racing hard my legs begin to hurt while my breathing remains relaxed.
- Yes
- No
I am uncomfortable riding in close quarters in a pack.
- Yes
- No
I become unnerved and lose my position easily when I am challenged for it during the wind-up before a sprint finish (cycling) or when a competitor comes upon me (cycling or running).
- Yes
- No
I become unnerved and lose my position easily when I am challenged
- Yes
- No
I can easily make my way through the pack from the back to the front without spending much time in the wind or wasting energy (cycling) or if I need to catch another runner, I can easily increase speed and then back off once I reach them.
- Yes
- No
I almost never have to brake before or during a corner during a race (cycling).
- Yes
- No
I almost never have to brake before or during a corner during a race (cycling).
- Yes
- No
Please communicate any other information you feel relevant.

WAIVER AND RELEASE OF LIABILITY
New Age Athlete Waiver and Release Form WAIVER AND RELEASE OF LIABILITY Please READ BEFORE SIGNING In consideration of being allowed to participate in any way in the New Age Athlete program, its related events and activities I, the undersigned, acknowledge, appreciate and agree that: 1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular skills, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of New Age Athlete immediately; and, 4. I agree to all pre-determined financial payments to New Age Athlete. I agree to payment in a timely manner. I agree to pay all collection fees; and, 5. I, for myself and on behalf of my heirs, assignees, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS, New Age Athlete, and its officers, officials, agents and/or employees, other participants, assigns, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for the activity ("Release’s), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property associated with my presence or participation, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Enter your full name as acceptance the Waiver and Release of Liability*

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