Heart Health Coaching Registration

First Name *

Last Name *

Address *

City *

State

Zip / Post Code

Country *

Phone *

Email *

Birthday *

Age *

Gender *

Male
Female

Height *

Weight *

Occupation *

Hours per week that you work

Married? *

Yes
No

Children? *

Yes
No

How did you hear about us? *

Please explain your cardiac issues *

Have you had a recent check-up from your doctor and have you been given the OK to participate in exercise? (If you have not had a recent check up, please schedule one with your doctor and talk to your coach) *

Yes
No

Do you follow a specific or special diet?

Do you have any other medical conditions or chronic injuries that may flare up & should be taken into consideration in developing you training plan?

What is your resting pulse (if known)?

Please explain any heart rate or exercise restrictions your doctor has given you

Do you participate in sports or activities? If so, which ones?

Describe your exercise training over the past 6 weeks

How many hours per week do you spend training now?

Describe your longest single workout in the last 3 weeks

How many days per week do you take off from training?

How much time do you have available for training each day?

What is the terrain and conditions in your area? (Hilly? Flat? Windy? etc.)

Do you have access to

Sports Watch (timing only)
Sports Watch (with GPS)
Heart Rate Monitor
Cycling Power Meter
Running Power Meter
Track
Trail
Treadmill
Pool
Bicycle
Swim Gear (paddles, fins, etc.)
Indoor Trainer (bike)
Free Weights
Resistance Bands
Gym

Are there any specific holidays or additional commitments or priorities that you would like us to consider as we design your workout schedule?

Are you currently recovery from any injury or illness? (if yes, please explain)

Yes
No

Please list any medications you are on

Please list any supplements you take.

Please list any medical conditions or injuries that your coach should be aware of.

Women: Do you track your monthly cycles?

Yes
No

Are you happy with your current weight and shape?

Anything else you'd like your coach to know?