Triathlon Intake Form

Personal Information

First Name (required)

Last Name (required)

Email (required) Phone Address Occupation

Emergency Contact

First Name

Last Name

Emergency Contact Phone

Health History Anyone in your family under 60 who has suffered heart disease, stroke, raised cholesterol or sudden death? Are you male over 35 or female over 45 and NOT used to regular vigorous exercise? Are you on prescription medication? Have you given birth in the last six weeks? Have you been hospitalised recently? Are you pregnant? Are there any other conditions which may be reason to modify your exercise program?

Current Exercise Habits What exercise have you been doing recently? For how long (please indicate months/years)? Duration per session (mins)? How often (daily, weekly)? For how long (months/years)? Intensity

Medical Details Please give details of medical condition, if any, and related medications:

Client Declaration

I recognise that the coach is not able to provide me with medical advice with regard to my medical fitness and that this information is used as a guideline to the limitations of my ability to exercise. I have answered the questions to the best of my ability and understand the advice above.

Client Signature - Please type your full name Date (dd/mm/yyyy)

Training Availability - Weekly Planner

Please fill out the times and duration you can realistically train around work and family. If you have a roster, please forward via email.

Day	AM	PM
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Any additional information that is useful:

Goals & Future Races Include a brief outline of short/long term goals: All future races you have planned over the following 6 months: