Health & Medical Questionnaire |

Name *

First

Last

Date of Birth *

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone *

Personal Physician Name *

Personal Physician Phone *

Email *

Have you had or do you presently have any of the following? *

Rheumatic fever
Recent operation
Edema (swelling of ankles)
High blood pressure
Low blood pressure
Injury to back or knees
Seizures
Lung disease
Heart attack or known heart disease
Fainting or dizziness
Diabetes
High Cholesterol
Orthopnea (the need to sit up to breath comfortably) or paroxysmal (sudden, unexpected attack) or nocturnal dyspnea (shortness of breath at night)
Shortness of breath at rest or with mild exertion
Chest pains
Palpitations or tachycardia (unusually strong or rapid beat)
Intermittent claudication (calf cramping)
Pain, discomfort in the chest, neck, jaw, arms, or other areas
Known heart murmur
Unusual fatigue or shortness of breath with usual activities
Temporary loss of visual acuity or speech, or short-term numbness or weakness in one side, arm, or leg of your body
Cancer
Other
None of the above

If other, please describe.

Have any of your first-degree relatives (parents, sibling, or child) experienced any of the following conditions? *

If other, please describe.

Please explain any checked items above including age at which the condition occurred.

Have you ever worked with a triathlon coach before? *

Please list previous coaches if applicable.

If you are currently working with a coach, have you communicated your desire to leave?

What was the date of your last physical examination by a physician: *

Have you ever performed resistance training exercises in the past?

Do you have injuries (bone or muscle disabilities) that may interfere with exercising?

If yes, briefly describe.

Do you smoke or use tobacco products?

If yes, briefly describe.

What is your body weight now?

What was your body weight one year ago?

What was your body weight at age 21?

How tall are you?

Do you follow or have you recently followed any specific dietary intake plan and, in general, how do you feel about your nutritional habits?

List any medications you are presently taking and why you take them.

Have you had a complete blood panel drawn in the past year?

Mile High Multisport