Smart Coaching, Programme Questionnaire
All information gathered by Smart Coaching limited is totally confidential and will not be used in any way other than the prescription of exercise for your chosen events.

This questionnaire enables smart coaching to determine how much time you have for training, but more importantly how much time and energy you have to recover from training. Please be honest and if anything does not make sense contact smart coaching to help you through this information gathering process.

If you have any trouble with this form please email silas@smartcoaching.org with the subject line "EMAIL FORM" and you will receive a form that you can fill in and subiit within the email you receive. This prevents any timing out issues.
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Personal Details
First Name *
Or name you prefer to be called.
Surname *
Contact email *
Preferably one you can check from home as well as work.
Phone Mobile (0) *
Contact address *
Communication *
How would you like to be contacted. What is the most convenient means of communication for you?
Do you have a different preferred app or mode of communication?
Occupation *
How did you hear about "Smart Coaching"? *
Medical
Date of Birth *
dd/mm/yy
Medication which could have an effect on your training? *
Any Previous Surgery, which could affect you training? *
Any relevant family medical History which could effect training?
Please Indicate “yes” or “no” if you have suffered from the following. [Heart murmur] *
Yes
No
Heart murmur
Palpitations / irregular heart beat
Angina / chest tightness with exertion
Heart attack
Thrombosis / blood clot
Stroke
Dizziness, light headed or passed out during or after exercise
Undue fatigue
Bronchitis / Asthma / Wheezing
Joint problems limiting activity / exercise
Any other factors which may limit activity / exercise
Recent virus infection
Family death before age 60
Have you ever been given exercise advice by a doctor or advised that you should exercise in a particular way?
High blood pressure
High cholesterol
Have you suffered from any other condition that may effect your ability to exercise? *
If so please give details.
If you have answered “yes” to any of the questions above please write a more detailed explanation.
How much do you weigh right now in kg? *
How much do you think you should weigh in kg? *
What is your height in centimetres? *
How would you rate your flexibility? *
Very inflexible
Very flexible
Goals and events, future and past
Please indicate the events and EXACT DATES you wish to participate in over the next eight weeks and up to three years and beyond if you know them. Include web links to the events if they have them.
Events and goals in the next eight to fifteen weeks. *
Please provide EXACT DATES and paste web links below.
Events and goals in the next six months.
Please provide EXACT DATES and paste web links below.
Events and goals in the next twelve months.
Please provide EXACT DATES and paste web links below.
Events and goals in the next three years.
Please provide exact dates and paste web links below.
What events have you completed in the past?
If you have completed events before then please provide details including dates, distances, times and placings. If you have a very long training history, then focus on the most relevant events to your current goals.
Injury History and Non Training Load
Injuries both past and current and things that take up your time and energy outside of training.
Last break *
If you are training now, when was the last time you had a complete voluntary break from training of 15 days or more? (NOT including injury, work trip, or a pause in training due to other commitments).
Have you ever suffered from injuries as a result of training or that restrict your training in any way?
If so indicate when, what type of injury and if the injury is still current.
If you have suffered an injury as a result of training, what did you find worked best as far as rehabilitation?
For example if you had petala tendonitis as a result of cycling or running, were there specific exercises you did that you felt worked well?
Do you live with a partner? *
Do you have any kids who live with you? If so how many and what ages?
Do you have any kids who live with you part of the time? If so when?
What are your hours of work? *
Rate the physical nature of your work. *
Sedentary desk job
Heavy physical labour
Rate the stress level of your work. *
No stress at all
Burning out
Do you work shift work?
If so please provide details of your shift pattern
Generally, how often do unforeseen work commitments affect your training?
What sports / disciplines are you currently training? Swim, bike run, kayak, mountaineering, Bobsleigh, ski wingsuit base jumping etc. *
How long for and to what level?
Current training *
Please indicate your current typical week of training. Provide as much detail as possible about the types of training as well as the length of training.
What is your idea of "fun training?" *
It could be doing hill reps, hammering on the flat pushing a big gear, bunch riding (cycling), off road running, group sessions, mountain biking, cross country skiing, gym sessions etc. Whatever sessions or even cross training sports you find most enjoyable.
How much time each day do you have for training? *
Include Morning, mid day and afternoon availability.
Rest Days *
If you were going to have a day or days off training, what days would suit you best? (Include first, second and third choices).
Freshest Days *
What days are you freshest / have the most energy to train?
When would you like your training program to start? *
Equipment *
List all the equipment you have that can be used in training, heart rate monitor, wind trainer etc...
Power data
If you have a power meter then please give details of the following - 1. Your Functional Threshold Power (FTP) preferably in a short race or TT in the last 3 months. 2. Your maximum 1 minute, 5 minute and 20 minute power in the last 6 months. If you use online software to store your data I will also log in and look at this. There is space below for your username and password.
Heart Rate data / observations
If you have a heart rate monitor then please give details of the following - 1. Max Heart Rate ever seen in the last 3 years. 2. The maximum sustainable heart rate you can hold for 40min (in your strongest discipline for multi discipline athletes) this would preferably be in a race. 3. Your resting heart rate in the morning lying in bed 3min after waking as sometimes it spikes when you first wake up. If you have any testing information please email it to silas@smartcoaching.org. If you do not know this info exactly have a guess based on what you have seen in the past. If you have no idea or have never used a heart rate monitor we can add this in later.
Where is your balance point? *
This scale reflects the balance point of your program. You might be single minded in your determination to improve performance or you might want to improve but having fun in your sessions may be more important to you. Either way your program needs to reflect your personality to be successful and for you to get what you want out of it.
Purely based on fun, training with others and enjoying each session.
Purely based on physiological adaptation and performance improvement.
Other information
Please list any other information that you think may be helpful for me in writing your training program even if you think it is not entirely relevant.
Waiver
Please read the following and type your name in the space provided at the bottom of the last page. By typing your name you indicate your understanding and agreement of the following text.

Smart coaching limited requires that you consult with your physician before following any training instructions you receive through Smart Coaching Limited. Neither Smart Coaching limited nor the coaching staff are licensed medical care providers and represent that they have no expertise in diagnosing, examining, or treating medical conditions of any kind, or in determining the effect of any specific exercise on a medical condition. Smart Coaching Limited and its coaching staff are not prescription systems and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. You should understand that when participating in any exercise or exercise program, there is the possibility of physical injury and/or death.

You should never disregard medical advice or delay in seeking it because of something you have read on the smart coaching limited web site or news letter. Smart coaching limited and coaching staff are not responsible for any health problems that may result from training programs you receive from them. If you engage in any training program you receive through smart coaching limited or coaching staff, you agree that you do so at your own risk, are voluntarily participating in these activities, assume all risk of injury to yourself, and agree to release and discharge smart coaching limited and coaching staff from any and all claims or causes of action, known or unknown, arising out of the actions of smart coaching limited or coaching staff. You agree to indemnify and hold harmless smart coaching limited and coaching staff for any loss, liability, claim, damage, and expenses (including reasonable attorneys' fees) brought by you, anyone acting on your behalf, or any third party, in any way arising from or in connection with your use of the information or services you receive through smart coaching limited or it's coaching staff.

Smart coaching limited and it's coaching staff are not responsible for the accuracy, reliability, effectiveness, or correct use of information you receive through the smart coaching limited web site, or for any health problems that may result from training programs, products, or events you learn about through smart coaching limited or associated coaching services. smart coaching limited and coaching staff do not certify content or endorse any information supplied by other companies for our Web site.

PLEASE NOTE: Not all exercises are suitable for everyone. Before you begin following any training instructions you receive, you should have permission from your physician to participate in vigorous training. If you ever feel discomfort or pain, do not continue. The instructions and advice presented by smart coaching limited are in no way intended as a substitute for medical consulting.

Limitation of Liability: smart coaching limited, coaching staff, and their affiliates and sponsors are neither responsible nor liable for any direct, indirect, incidental, consequential, special, exemplary, punitive or other damages arising out of or relating in any way to the smart coaching limited Web site or the coaching services provided by Smart Coaching limited or coaching staff. Your sole remedy for dissatisfaction with the services provided is to stop using those services.

Waiver and Indemnity: Your use of any services and information obtained through smart coaching limited, including but not limited to the coaching services of our coaching staff, certifies that you have read this Agreement and hereby for yourself, your heirs executors and assigns, waive, release and hold harmless smart coaching limited and coaching staff from any and all claims, demands, liabilities, rights or causes of action arising out of or in connection with participation in activities proscribed by the aforementioned parties.

You agree to defend, indemnify, and hold smart coaching limited, coaching staff and their officers, directors, employees, agents, licensors, and suppliers, harmless from and against any claims, actions or demands, liabilities and settlements including without limitation, reasonable legal and accounting fees, resulting from, or alleged to result from, your violation of the terms and conditions of this Agreement.

If you are going to participate in one of smart coaching limited's training programs, you need to start by answering the seven questions in the box below. If you are between the ages of 15 and 69, this will tell you if you should check with your doctor before you start. If you are over 69 years of age and you are not used to being very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly. Make a note of which questions (if any) you answer YES to.
Please answer the following [Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?] *
Yes
No
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 physically active?
Do you lose 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 your blood pressure or heart condition?
Do you know of any other reason why you should not do physical activity?
If you answer yes to one or more of these questions... [By ticking yes you understand and agree to all the terms and conditions set out in this waiver.] *
Talk with your doctor by phone or in person BEFORE you start becoming much more physically active or BEFORE you contact us or begin training on a training program. Tell your doctor about the PAR -Q and which questions you have answered YES. You may be able to do any activity you want - as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the activities you wish to participate in and follow the advice. Find out which programs are safe and helpful for you. NO to all questions If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming more physically active – begin slowly and build up gradually. This is the safest and easiest way to go. Start using a Smart coaching limited training program, provided you complete this PAR-Q and the subsequent medical / training questionnaire honestly. DELAY BECOMING MUCH MORE ACTIVE: If you are not feeling well because of a temporary illness such as cold or fever, wait until you feel better OR If you are or may be pregnant – talk to your doctor before becoming more active. PLEASE NOTE: If your health changes so that you then answer YES to any of the above questions, tell your Coaching and/or health professional. Ask whether you should change your plan. I ACKNOWLEDGE THAT: During the duration of my training program (or whilst following the components within the training program) both my property and my person shall be at risk and I will not hold www.smartcoach.co.nz / Smart coaching limited Pty Ltd liable for any personal injury or loss of property. I do not have the right of action against www.smartcoaching.org / Smart coaching limited Pty Ltd or any employee or agent of these parties in respect of any injury, loss or damage occurring during the period of my program (or whilst following the components within the training program). I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction by smart coaching limited staff (email: silas@smartcoaching.co.nz if you need to clarify any of the above).
Yes
No
By ticking yes you understand and agree to all the terms and conditions set out in this waiver.
Photo of you please!
If you have a photo's of yourself training or racing that we could use to personalise your information page, this would be much appreciated. This will make your site look cool! As well as help with motivation. Please email your photo to info@smartcoaching.org
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