Questionnaire

warning

BY COMPLETING THIS QUESTIONNAIRE YOU CONFIRM THAT YOU PRESCRIBE TO THE FOLLOWING ETHICAL STATEMENT and Acknowledgment of risk, release of liability, indemnification agreement and covenant not to sue

I believe that, as an athlete with high ethical standards, I will train and compete according to the rules and ethics of sport. I believe that athletes should avoid the use of banned substances to prevent potential health risks and I will abide by the purest rules of sport. I am an athlete who competes and trains “clean” and I know that success comes from preparation, tactics and teamwork rather than something that comes in a pill or from a needle. As such I will abide by all the rules of USA Cycling, the UCI, or the United States Olympic Committee depending on jurisdiction.

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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
Gender
- Male
- Female
Name
First Last
Address
Street Address City State ZIP Code
Home Phone
Work Phone
Cell Phone
Pager
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
Health
If you reply yes to any question please provide details and clearances.
Have you had a physical in the last year by a licensed physician?
Were you cleared to participate in exercise programs?
Has anyone advised you to limit your exercise?
Have you or anyone in your family had heart disease/trouble or high cholesterol?
Have you ever had chest, shoulder, neck or arm pains after exercise?
Have you ever fainted, felt dizzy, or unusually winded after exercise?
Do you have high blood pressure?
Are you diabetic?
Do you have a thyroid condition?
Women: are you pregnant or have you been pregnant in the last 3 months?
Describe any allergies (in detail including medication)
List ALL injuries, surgeries etc. that might influence your exercise
List any medications you are currently taking
List any nutritional supplements you use
Athletic History
Athletic Genealogy (Dad, Mom, Siblings)
Started cycling
Bicycle racing license
License expiration
License upgrade info
Racing experience
Do you keep a training diary or log? If yes please send.
Have you ever worked with a coach? If yes please send most current Mesocycle.
Do you have access to a facility that has weights or weight machines?
Have you ever lifted weights for training?
Team memberships
Sponsorships
Describe your bicycle (gearing, fork, shocks, special clothing)
Describe your training equipment (heart rate monitor, rollers, fixed trainer etc.)
Current Cycling Commitment (describe what 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
Time commitment available to attain your goal (Aim for 9 to 12 hours per week). Provide typical group rides that you can or do participate in.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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
Phone
This field is for validation purposes and should be left unchanged.

Questionnaire

BY COMPLETING THIS QUESTIONNAIRE YOU CONFIRM THAT YOU PRESCRIBE TO THE FOLLOWING ETHICAL STATEMENT and Acknowledgment of risk, release of liability, indemnification agreement and covenant not to sue

Personal Information

Health

Athletic History

Cycling Goals (be specific as possible)