Updated Athlete Questionnaire

Updated Athlete Questionnaire for 2017

Section

Welcome!

We know that you have a choice for your coaching; thank you for choosing BPC! Keeping this questionnaire current is essential for your coach to effectively help you attain your goals. The more thought you put into your responses, the more your coach will be able to target your training. This process will take approximately 30 minutes to complete. You will not be able to save your progress so when you are ready, grab a cup of coffee, and let's get started. If you are not ready at this time, please bookmark this page so you can return to it.

Contact Info

First Name *

Last Name *

Email *

Phone Number *

Address *

Address Line 2

City *

State *

Postal Code *

Occupation

We'd love to follow you on social media; let us know your usernames!

Facebook

Instagram

Twitter

Other

Athlete waiver and release from liability

In consideration of being given the opportunity to participate in the coaching program ("program") designed by Breakthrough Performance Coaching, LLC (TeamBPC). I, for myself, my personal representative, assigns, heirs, and next of kin:

A. ACKNOWLEDGE, AGREE AND REPRESENT that I am fully aware that participating in any exercise program can be a potentially dangerous, hazardous activity, and I am specifically aware that the Program involves risks and dangers of serious bodily injury, including permanent disability, paralysis and death (“Risks”). I also fully understand that these Risks may be caused by my own actions, or inactions, the actions or inactions of others, the negligence of any Releasee named below, and that there may be other risks and social and economic losses either not known to me or not readily foreseeable at this time. I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I INCUR AS A RESULT OF MY PARTICIPATION IN THE PROGRAM. *

Yes

B. HEREBY RELEASE, discharge, and covenant not to sue Jeffrey Capobianco, Breakthrough Performance Coaching, LLC (Team BPC), its instructors, members, directors, agents, independent contractors, officers, volunteers and employees, any sponsors, advertisers and, if applicable, any owners and lessors of premises on which any portion of the Program takes place (each considered a “Releasee” herein), from all liability, claims, demands, losses or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasee or otherwise; and I further agree that if, despite this release and waiver of liability, assumption of the risk, and indemnity agreement, I, or anyone on my behalf, makes a claim against any Releasee, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS such Releasee from any litigation expenses, attorney fees, loss, liability, damage or costs which any may incur as a result of such claim, to the fullest extent permitted by law. *

Yes

C. UNDERSTAND that Jeffrey Capobianco, and Breakthrough Performance Coaching, LLC (Team BPC), do not offer medical advice, establish a doctor-patient relationship or keep any permanent medical records about me. All medical questions that I may have while participating in the Program must be directed toward my personal physician. *

Yes

D. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT *

Yes

I verify that I am at least 18 years old and parental consent is not required for me to participate in the program provided by Breakthrough Performance Coaching, LLC *

Yes

Signature *

Draw It
Type It
Clear

Coach *

Plan *

Personal Information

Date of birth *

Gender *

Height *

Weight (lbs) *

Body Fat (%)

Medical Information

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? *

Do you feel pain in your chest when you do physical activity? *

In the past month, have you had chest pain when you were not doing physical activity? *

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Do you know of any other reason why you should not do physical activity? *

If you answered "YES" to any of the above questions, or have any other medical conditions, please explain below

Medications

Allergies

Any "nagging" injuries or susceptibility to injury (i.e., ITBS once I hit 40 running miles per week)?

Emergency Contact Info

Full Name *

Contact Number *

Athletic Background

Performance Goals

These are outcome related goals (e.g. Finish top 10 in my age group, complete my first sprint, or qualify for Ironman World Championships)

Goal #1 *

Goal #2 *

Goal #3 *

Training Goals

These are things you need to work on every day to help you obtain your performace goals (e.g. Eat a healthy diet, fuel your workouts properly, or ride at a steady power output)

Goal #1 *

Goal #2 *

Goal #3 *

Race Schedule

Please add your race schedule for 2015 (with dates)

Top priority race *

Second priority race *

Third priority race

Additional races

What is working will, with regards to your training and coaching? *

What is working well for you in your training? What is the major area in training which you are spending a lot of time thinking about? What are the types of feedback from me that you find make you feel most successful or motivated? Anything I need to know right now to design your training in the most effective way possible? *

What are the types of feedback from me that you find make you feel most successful or motivated? *

What is the major area in training which you are spending a lot of time thinking about? *

Swim Section - Self-Assessment

1=Beginner/Very uncomfortable, 5=Expert/Very comfortable, N/A=Not applicable, D/K=Don't know

Swimming in Pool *

Swimming in Open Water *

Swimming in Wetsuit *

Please Check all of the equipment that you have and/or use. *

Please let your coach know if you'd like to learn more about any other above equipment.

What do you think are your swim limiters? *

What do you think are your swim strengths? *

Bike Section - Self-Assessment

1=Beginner/Very uncomfortable, 5=Expert/Very comfortable, N/A=Not applicable, D/K=Don't know

Years that you've been cycling?

Recent average weekly cycling volume in hours?

Recent average weekly distance?

Longest ride to date?

What do you think are your cycling limiters? *

What do you think are your cycling strengths? *

Run Section - Self-Assessment

1=Beginner/Very uncomfortable, 5=Expert/Very comfortable, N/A=Not applicable, D/K=Don't know

Years that you've been running?

Recent average weekly run volume in hours?

Recent weekly distance in mileage?

How comfortable are you with trail running?

How comfortable are you with speed work/track workouts?

What do you think are your running limiters? *

What do you think are your running strengths? *

Nutrition Section - Self-Assessment

1=Beginner/Very uncomfortable, 5=Expert/Very comfortable, N/A=Not applicable, D/K=Don't know

My day to day nutrition is: *

My workout fueling is: *

My race fueling is: *

Psychological Section - Self-Assessment

My mental fortitude during workouts is: *

My mental fortitude during races is: *

Your Goals, Our Knowledge, Unstoppable!

Your Goals, Our Knowledge, Unstoppable!