Bike Fit Questionnaire

BY COMPLETING THIS QUESTIONNAIRE YOU CONFIRM THAT YOU acknowledgment and agree to the risk, release of liability, indemnification agreement and covenant not to sue and agree to receive SMS appointment reminders

In consideration of purchasing a bike fit from P. Dave Jordaan dba CyberCycleCoach (Releasees) I understand, agree and do not object to the fact that bike fit at times involves touching and adjustment of the body by the fitter and hereby freely agree for myself, my heirs, executors, administrators, legal representatives, assignees, and successors I HEREBY WAIVE, RELEASE, DISCHARGE, HOLD HARMLESS, AND PROMISE TO INDEMNIFY AND NOT TO SUE the Releasees that are in any manner connected with bike fitting FROM ANY AND ALL RIGHTS AND CLAIMS INCLUDING CLAIMS ARISING FROM MY OR THE RELEASEES’ OWN NEGLIGENCE, which I have or which may hereafter accrue to me, and from any and all damages which may be sustained by me directly or indirectly in connection with, or arising out of, my participation in or association with a bike fit including travel to or return from the bike fit. I also consent to receive SMS from P. Dave Jordaan dba CyberCycleCoach to confirm appointments. To opt out do not agree to agree to this release.

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- Yes, I prescribe to the ethical statement and Acknowledgment of risk, release of liability, indemnification agreement and covenant not to sue
Personal Information
Referred By
Name
First Last
Address
Street Address City State ZIP Code
Cell Phone
Email
Occupation
Hours Worked
Number of hours worked each week
Birth Date
Height
Weight
Clothing Size
small, medium, large
Shoe Size
US & European if you know it
Foot Peculiarity
high arch, wide, etc.
Resting Heart Rate
Waking 3 day average for full 60-second count
Max Heart Rate
Highest seen within the last 12 months
Athletic History
Started cycling
Current level
Racing experience
Team memberships
Have you ever had a professional bike fit? (If yes - describe)
Describe your bicycle (Year, Frame, Gruppo, Saddle, Comment)
Type of braking system
Describe your training equipment (heart rate monitor, rollers, fixed trainer etc.)
Describe all the excercise you currently do
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Describe your Cycling Hydration, Energy Gel, Food Bar habits
Pre-Ride
During Ride
Post-Ride
Cycling Goals (be specific as possible)
Short term goals
Medium term goals
Long term goals
What do you consider to be your strengths as a cyclist? Please explain
What do you consider to be your weaknesses as a cyclist? Please explain
Email
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Bike Fit Questionnaire

BY COMPLETING THIS QUESTIONNAIRE YOU CONFIRM THAT YOU acknowledgment and agree to the risk, release of liability, indemnification agreement and covenant not to sue and agree to receive SMS appointment reminders

Personal Information

Athletic History

Cycling Goals (be specific as possible)