ELITE SPORTS SPECIALIST - SCREENING QUESTIONNAIRE
Name: DOB: Age: Sex:
Address: State: Postcode: Country:
Telephone (H): (W): (M):
Email contact 1: Email contact 2:

In order for us to gain a full understanding of your profile and individual needs, it is necessary that you provide us with as much information and detail as possible. Please complete this questionnaire, and provide us with as many details as you can. The greater level of understanding and insight that we can gain of your past and present history, individual goals and circumstances, enables us to provide you with the correct and most suitable and effective training program.
TRAINING AND EXERCISE HISTORY:
Have you had any professional coaching? Yes: No: How long:
What type of training have you done?
How long have you been training at your current level?
On the table below, please describe your current training, giving as much detail as possible.
Day
Type of activity
Duration/hours
Distance/time
Time available to train

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
** Activity means a single discipline ie Running, cycling, swimming, resistance training, yoga etc
Is the above training schedule your maximum time availability? Yes: No:
If no, how many more hours per week do you have available?
Do you currently have regular massages? Yes: No:
If yes, how often?
Do you foresee any constraints that may slow or limit your progress? (eg time limits, injury, work etc)
PERSONAL PROFILE:
Body Weight: Height:
Does your weight fluctuate?
Yes:
No:
By how much?
Do you do resistance training?
Yes:
No:
How often?
What exercises do you perform in your program?
How many sets? How many reps?
Do you currently stretch or participate in Yoga?
Yes:
No:
How often? /week
Do you own a heart rate monitor?
Yes:
No:
What is your resting HR?
What is your lactate threshold during race season?
Do you have access to a lactate machine?
Yes:
No:
Do you own a windtrainer?
Yes:
No:
ACTIVITY PROFILE:

Please provide details of key race times, including total race time and heart rate details.
Swim HR or 1500m time: Swim pace per 100m:
Cycle HR or 40km TT time: Cycle speed in km/hr
Cycle power output: Run HR for 10km:
Run pace per km : Time for Ironman run :
Do you swim in a squad?
Which Squad?
Number of times per week:
Do you cycle in a group?
Which Group?
Number of times per week:
Do you run with a squad?
Which Squad?
Number of times per week:
Please rank your strengths and weaknesses on the follow table:

 

EXCELLENT

GOOD

AVERAGE

WEAK

CYCLING

 

 

 

 

Low Gear Spinning

Big Gear Seated

Big Gear Standing

Time trial – Flats

Hill Climbing Standing

Hill Climbing Seated

RUNNING

 

 

 

 

Long Runs 20km +

Shorter Runs 5km-15km

Steep Hills 8%

Gradual Long Hills

Leg Speed

SWIMMING

 

 

 

 

Body Position

Hip Flexibility

Rhythmic Kick

Long Swims

Shorter Swim/Speed

STRENGTH

 

 

 

 

Hamstrings

Quadriceps

Glutes

Lower Back

Lats

Mid Back

Triceps

Rotators

Abs

Calves

GOALS
Improve Half Ironman Time Improve Swim

Stress Management

Improve Ironman Time Injury Rehabilitation Relieve Boredom
Improve Run Time Toning & Shaping Competitive Edge
Improve Cycling Strength & Development Increased Fitness
Competition Goals:

Please give details of your most recent event results and your swim/bike/run splits if your event was a triathlon:

Race Name
Distance
Date
Overall Time
Swim
Bike
Run
INJURY PROFILE
Are you currently injured?
Yes:
No:
Details:
Have you had any other injury problems?
Are these ongoing or acute?
Ongoing:
Acute:
Details including year that injury began, and how many years it has been ongoing:
MEDICATIONS
Are you taking any medications?
Yes:
No:
If yes, please give details:

 
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