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Runner's Questionnaire

Instructions

In order for Coach Komen to plan your training regimen, he must first evaluate your running history, current level of fitness, and general health. Please answer the questions on this form completely and as specifically as possible.

The information gathered here will be used solely by Wilson Komen for creating your training plan. He will not share your information with any other person or entity. Your personal information is strictly confidential. If you have any questions or concerns about completing this form, contact Coach Komen.

Please note that the coaching provided by Wilson Komen of Coach Kiprunning is not intended in any way as a substitution for professional medical advice. If you have questions or concerns about your exercise regimen, personal nutrition, injury status, or your overall health, please contact your primary care physician for further assistance.

The Questionnaire

Name *

First

Last

Street Address 1 *

This field only requires a street address. Add any apartment number information in the optional "street address 2" field.

Street Address 2

Please enter your apartment or unit number, if appropriate, here.

City *

State *

Postal Code *

Country *

Phone Number *

Please enter your complete phone number with area code and, as necessary, country code.

Email *

Confirm Email

Skype Name (optional)

If you are an international trainee, Coach Komen might suggest that you communicate through Skype. Please enter your Skype name if you have an account.

Communication Preference (for trainees not local to Washington, DC)

Phone
Email
Skype

If you are not local to Washington, DC, indicate your preferred method of communicating with Coach Komen.

Age *

Sex *

Height *

Weight *

Resting Heart Rate *

Have you been diagnosed with: *

This information will help Coach Wilson design an appropriate training plan.

Describe your running injury history: *

Please offer Coach Komen as much detail as possible. What type(s) of injury? Were you treated? Are you currently injured? Have you been cleared to run? Describe any previous training or racing difficulties.

Total Years Running *

Miles Run Per Week (in the past month) *

Rough averages acceptable

Fastest Long Run (past two weeks; distance and time) *

Rough averages acceptable

Fastest Short Run (past two weeks; distance and time) *

Rough averages acceptable

Distances Raced (list all) *

Personal Racing Records (list all) *

To the best extent possible, list name of race, date of race, distance, and your official time.

Current Racing Goals *

Personal Coaching Experience *

Discuss experience with past personal running coaches. If none, explain why you are seeking personal coaching. What are your general running goals?

Additional Regular Exercise *

You may list regular yoga, strength training, or other regular exercise regimens. If none, type "none."

How many days per week do you plan to run? *

Coach Komen will use this information to begin drafting your training plan.

Specify Running and Rest Days *

Example: Monday-run; Tuesday-run; Wednesday-rest; etc.

Desired Long Run Day *

Generally, long runs are scheduled during the weekend.

Speedwork Day *

Generally, speedwork is scheduled for the middle of each week. These workouts will take, on average, one hour to ninety minutes.

Upcoming Races

If you are planning to run any races during your training, please list them here.

Additional Comments

Feel free to add any additional comments about your training, racing, or medical history that you think will helpful to Coach Komen.

Name