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COACH SCOTT
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COACHING REQUEST
COACHING REQUEST
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Terms and Conditions
Coaching Request
Name:
Email:
Phone:
Message:
Age
Height
Weight
Occupation
Sport
Marathoner
Triathlete
Other
What Events do you have scheduled or planned?
Do you have any health/injury/medical history we should be aware of?
Equipment (Check all that you have)
GPS Device
HR monitor
Powermeter (not required)
Health History/Symptoms *Checking a box indicates that you have had that sign or symptom
Heart Attack
Heart Surgery
Cardiac Catherization
Coronary Angioplasty
Heart Valve Disease
Heart Failure
Heart Transplantation
Congenital Heart Disease
I experience chest discomfort or pain with exertion
I experience unreasonable breathlessness
I experience dizziness, fainting or blackouts
Take Heart Medication
Have diabetes
Have asthma or lung disease
Musculoskeletal Problems that limit physical activity
Have concerns about the safety of exercise
pregnant
NONE OF THE ABOVE
Cardiovascular Risk Factors * Checking a box indicates that "Yes"
Male older that 45 or Female older that 55
You have a close blood relative who had a heart attack or heart surgery before age 55 (father or brother)
You have a close blood relative who had a heart attack or heart surgery before age 65 (mother or sister)
You smoke, or quit smoking within the previous 6 month
Your blood pressure is >140/90 mm Hg
Your blood cholesterol level is >200mg/dl or LDL >130 or HDL<40
You are physically inactive (i.e., you get <30 minutes of physical activity on at least 3 days per week).
Your doctor has told you you are obese, BMI>30, male waist circumference greater that 102 cm or female waist circumference greater than 88cm
None of the above
Shirt Size
I have read, understand and agree to the Terms and Conditions document which includes but is not limited to:
Terms and Conditions, Informed Consent / Assumption of Risk, Media Release
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Coach Scott
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Co
aching Request
Terms and Conditions
Where To Find Us
7391 Osceola Rd, Blanchester OH 45107-9375, United States
+1 (845) 546 7677
SCOTT@VIPENDURANCERACING.COM
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