PBT Private Coaching Profile

Your Name * First Last

Email *

Height

Approximate Weight

place your approximate weight at the time of this writing.

Running History

Please fill out all that applies.

How many years have you run?

How many consecutive years have you run?

Personal Bests

Please select your personal bests for each of the races you've completed. Include the year they were recorded.

400M

800M

1500M

1600M

Mile

3000M

Steeplechase (3K)

3200M

5000M

8K

5M

10K

15K

10M

Half Marathon

20K

25K

Marathon

Another Personal Best

Current and Past Training

Please answer the following questions regarding your training for the given periods.

Average Weekly Mileage Last 3-6 Months

Average Weekly Mileage Last 12 Months

Highest Weekly Mileage Last 3-6 Months

Highest Weekly Mileage Last 12 Months

Days of Running Per Week Last 3-6 Months

Days of Running Per Week Last 12 Months

Average Long Run Last 3-6 Months

Average Long Run Last 12 Months

Longest Run Last 3-6 Months

Longest Run Last 12 Months

Does your current training include the following components? Check All That Apply.

Long Runs Steady State, Tempo or Pace Runs Speedwork Cross Training Strength Training Cycling Swimming Do You Use a Heart Rate Monitor?

Please Describe any other Types of Training in Which You Engage.

How Often Do You Race?

Injury History

Please describe any significant or current injuries.

Running Goals

What are your short, intermediate and long term running goals?

Health History Questionnaire

Have you ever had an exercise stress test?

Yes No

If yes, please give the date and location of the test.

Person to contact in case of an emergency First Last

Relationship

Past Medical History

Have You Had The Following Medical Conditions? Please Check All That Apply

High Blood Pressure Disease of the arteries Lung disease Kidney Disease Diabetes Arthritis Any heart trouble Varicose veins Asthma Hepatitis Heart murmur

Family History (Have any immediate family of grandparents had?) Please Check All That Apply

Heart attacks High cholesterol Diabetes Heart operations High blood pressure Stroke Early death Congenital heart defect

Please Describe Any Other Family Illnesses

Current Symptoms (Have you had this recently?) Please Check All That Apply

Chest pain discomfort Heart palpitations Cough on exertion Dizzy spells Back pain Shortness of breath Skipped heart beats Coughing of blood Frequent headaches Orthopedic problems

Additional comments (please include any other medical problems/concerns not already identified)

Reason and Locations for Hospitalizations

What is your cholesterol level and when was it taken last ?

What prescription medications are you taking and why?

If you are currently dieting, please describe below.

Personal Questionnaire

What is your current occupation?

Spouse or Significant Other Name First Last

Spouse or Significant Other Occupation

If you have children, what are their names and ages?

In addition to running, what other interests do you have?

Statement of Inherent Risks of Program and Release

The Personal Best Training Program is a private coaching program designed to improve running performance through training principles founded upon moderation and individualization. However, the program will involve training at various levels of effort, some of which may be difficult.

I understand that participation in this Program involves physical exertion at many different levels. By agreeing to participate in this Program, I am acknowledging that my present physical health will allow me to engage in such participation and in the Program in general.

I recognize that participation in this program is accompanied by inherent risks of muscle or joint injury, abnormal heart rate and blood pressure, stroke, heart attack, and even a risk of death. I am also aware that if I experience symptoms such as fatigue, shortness of breath, dizziness, chest discomfort, or muscle or joint pain, I should stop exercising immediately and if such symptoms persist should seek the services of a physician.

I agree that I have been fully informed as to all benefits and risks of this Program and agree to release, discharge, and hold free and harmless Matt Ebersole, his assistants, and anyone else who may conduct or give advice in this Program and their successors, assigns and agents from any and all liability for injuries to property or person suffered by me as a result of my participation in this program.

I have voluntarily chosen to participate in this program, and I have a full understanding of the risks, benefits, and safeguards of this Program and understand this document fully and voluntarily agree to execute this document.

Participant’s signature

Parent’s Signature (if Participant is under the age of 18)

Greg Albright Design