Personal Inventory


Personal Inventory Form

 

Please answer the following questions as completely as possible.  All information is voluntary and personal information will be kept strictly confidential. 

 

Name: ________________________________________________Date of Birth:___________Age:_____

 

Medical Background

 

Are you currently under the care of a physician?  Yes No    If yes, please explain:

 

Please list any medications you are currently taking: 

Name of Medication                           Purpose for taking

_________________________          __________________________________________

_________________________          __________________________________________

_________________________          __________________________________________

 

Have you had a complete physical in the past year?  Yes No    

 

Smoking history (please select one choice):

 Currently Smoke

 Quit less than one year ago

 Quit over one year ago

 Never smoked

 

Please check all of the following that apply to you.  Please explain in the space provided or attach a separate sheet.

 Have you or anyone in your family had coronary artery disease?

 Have you ever fainted or felt dizzy after exercise?

 Has a doctor ever said that your blood pressure is too high?

 Do you have heart trouble, a heart murmur or have you had a heart attack?

 Do you have diabetes, thyroid condition or any other chronic condition?

 Are you now or have you been pregnant during the last three months?

 

Please explain any answers you marked with a yes:

__________________________________________________________________________________________________________________________________________________________________________Do you have any conditions that you or your doctor says may limit your physical activity?  Yes No    

If yes, please explain:

 

Please list (including dates) any current and past injuries/conditions that have limited your physical activity.

Injury/condition:________________________________________ Date: ______

            Injury/condition:________________________________________ Date: ______


Fitness Background

Please circle one:

I have been Running         Run/Walk        Walking

 

For how many Months_____  and/or Years____ consistently.

 

What is the approximate length (in miles or minutes) of the longest runs/walks for each of the last six weeks?   Miles    Minutes (please check one)

 

Week 1:       Week 2:       Week 3:       Week 4:       Week 5:      Week 6:      

 

How many days per weeks do you run, run/walk or walk (circle mode)?  __________________

 

Please list any other activities you currently engage in (i.e. strength training, aerobics, other sports, etc.):

Activity: ________________________________Minutes/day:       Frequency (# of times/week):      

Activity: ________________________________Minutes/day:       Frequency (# of times/week):      

 

What is your Primary training goal for this training program? (You may rank multiple goals: 1=Primary)

 Finish the race

 Weight Loss / Fat Reduction

 Improve my race time

 Have fun

 Improve level of fitness

 Meet people

 Maintain current level of fitness

 To learn about Living a Healthy Lifestyle

Other:________________________________________________________________________________

 

Distance Training Group Questions ONLY

 

What is the approximate length of your longest runs over the last six weeks? ______________

 

How many days per week do you usually run? _______________________

 

What is your typical long run training pace: __________ min/mile (i.e. 10 min/mile).

 

Have you done any track workouts in the past?  Yes   No  

 

How many of the following distances have you completed and what is your personal best time and date for each?

 

 

# Completed

Most Recent Time

Date of Most Recent Time

Best time

Date of Best Time

5K

 

 

 

 

 

10K

 

 

 

 

 

½ Marathon

 

 

 

 

 

Marathon

 

 

 

 

 

 

Please let us know of any other information you feel would be important for us to know regarding your fitness or health background.

Thank you!!!!

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