Personal Information

First Name:		*
Last Name:		*
Address:		*
City:		*
State:		select a state None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *
Zip / Postal Code:		*
Country:		Australia Austria Belgium Bosnia Herzegowina Brazil Bulgaria Canada China Czech Republic Croatia Denmark Estonia Finland Faroe Islands France Germany Greece Hungary Iceland Ireland Israel Italy Japan Korea Latvia Luxemburg Mexico Mongolia Netherlands Norway< option value="pl">Poland Portugal Romania Russian Federation Singapore Slovak Republic Slovenia South Africa Spain Sweden Syria Switzerland Tibet Turkey United Kingdom USA *
E-mail:		*
Phone:
Fax:
Sex:		Select your sex Male Female *
Date of birth:		* (mm/dd/yyyy)

Yes  No *

Do you have high blood pressure?
Yes  No *

Athletics Kind:
How long:

What is your athletic history?

Have you had any athletic related injuries in the last 2 years? If so, Explain.

Body fat:		%
Maximum heart rate Running:
Anaerobic HR (AT) Running:
Speed at AT Running:
Maximum Speed:
VO2MAX Running:
Maximum heart rate Cycling:
Anaerobic HR (AT) Cycling:
Power in Watts at AT Cycling:
Power in Watts at max HR:
VO2MAX cycling:
How, where and when did you do these tests (what kind of tests)?: What kind of job do you have, i.e.……hard labor or desk job?
How many hours a week do you work?:

Cycling: 40 Km PB (race)		Year:
How many miles did you ride last year, approximately?:
How many miles do you average per week on the bike?:

Run:		1 mile PB:				Year:
		5 km PB:				Year:
		10 km PB:				Year:
		1/2 Marathon PB:				Year:
		Marathon PB:				Year:

How many miles did you run last year, approximately?:
How many miles do you average per week running?:

Swim:		100 m PB:				Year:
		1000 m PB:				Year:

How many meters did you swim last year, approximately?:
How many meters do you swim average per week?:

What areas of athletic performance do you consider your strengths?

What areas of athletic performance do you consider your weaknesses?

What areas of athletic performance do you feel need particular attention?

What is/are your goal race(s) for the next three months?

What is/are your goal race(s) for the next six months?

What is your goal race for next year?

What are your long-term goals for the next two to three years?

Please provide any additional information or recommendations that may be useful in making an effective individualized program for you.

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Submission Agreement
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