AquaTerra Coaching, LLC
Triathlon Training
Triathlete Intake Form
Required items marked with red asterisk. All others optional. You will be able to save your answers and return later if necessary.
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
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California
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Connecticut
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South Carolina
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Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mobile Phone Number
*
Home Phone Number
Work Phone Number
Primary Email
*
example@example.com
Secondary Email
Optional
What is the best way to contact you?
*
Phone call
Email
Text
Messenger
Other
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Mobile Phone Number
*
USAT Membership # (if applicable)
Leave Blank if not a member of USA Triathlon
USMS Membership # (if applicable)
Leave Blank if not a member of US Masters Swimming
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Health and Medical
Required items marked with red asterisk. All others optional.
Gender
Male
Female
Other
Preference
Preferred Pronouns:
Optional
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
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December
Month
Please select a day
1
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31
Day
Please select a year
2025
2024
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2022
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2020
2019
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2012
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1928
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1926
1925
1924
1923
1922
1921
1920
Year
Height
*
Feet/Inches (i.e., 5ft 9in)
Weight
*
lbs
Resting Heart Rate
*If Known
Max Heart Rate
*If Known
Resting Blood Pressure
*If Known
VO2 Max
*If Known
Do you suffer from or have a history of:
*
NONE
Asthma (diagnosed)
Shortness of breath with or without exercise
Pulmonary disease or disorder
Diabetes Type 1
Diabetes Type 2
Fainting or light-headedness
Chest discomfort with exertion
Rapid or runaway heartbeat
Skipped heartbeat
Heart attack
Bypass or cardiac surgery
High blood pressure
Low blood pressure
High cholesterol
Orthopedic problems, including arthritis
Stroke
Other
Recent hospitalizations
Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?
*
Yes
No
Prefer not to answer
Are you currently taking prescribed medications for a chronic medical condition?
*
Yes
No
Prefer not to answer
If Yes, please list your medications and how long you have been taking them.
If you are on any medications not previously mentioned, including multivitamins, please list them here, including how long you have been taking them.
Leave blank if none.
Has your doctor ever said you have a heart condition?
*
Yes
No
Prefer not to answer
If Yes, please explain.
Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?
*
Yes
No
Prefer not to answer
If Yes, please explain.
Do you have any pain or issues in your:
NONE
Head/Neck
Upper Back
Shoulders
Arm/Elbow
Wrist/Hands
Lower Back
Hips/Pelvis
Thigh/Knees
Feet/Ankles
Other
Hernia
Please describe any physical limitations
Muscular, Skeletal, Numerological, etc. (Optional)
Within the last 24 months, have you experienced dizzy spells, lose balance because of dizziness or have you fainted or lost consciousness (other than sleep)?
Yes
No
I prefer not to answer
If yes to the above question, please list the condition(s) / occurrence(s) here.
Optional
Please list any injuries or surgeries you have had in the past five years.
Leave blank if none.
If you have any other health problems not previously mentioned, please list the condition(s) here.
Diagnosed or suspected. Leave blank if none.
If yes, please explain.
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Dietary Concerns
All items are optional to answer, but extremely helpful
Please rate how you feel your current nutritional habits are
I don't worry about what I eat, I just eat whatever, wherever.
1
2
3
4
I am very conscious of my food choices and eat whole foods fruits, and vegetables, and limit my processed food intake.
5
1 is I don't worry about what I eat, I just eat whatever, wherever., 5 is I am very conscious of my food choices and eat whole foods fruits, and vegetables, and limit my processed food intake.
Typical number of meals per day
Please Select
1
2
3
4
5
6+
Include planned snacks
Typical number of calories per day (if known)
Please Select
Less than 1500
1500-2000
2000-2500
2500-3000
3000+
Include planned snacks
Are you on any specific food/diet plan at this time?
Yes
No
Prefer not to answer
If Yes, please specify
Diet Plan (Macro counting, Keto, Paleo, etc.)
Dietary Restriction(s). Select all that apply
None
Allergies
Diabetic
Gluten Free
Kosher
Lactose intolerant
Dairy Free (100%)
Pescatarian
Vegetarian
Vegan
Food Allergies
Other
If Yes to Food Allergies or chose Other, please specify
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PARA ATHLETES ONLY
All items are optional to answer, but extremely helpful
USAT Open Classification
Yes
No
USAT / WTC Classification
Please Select
PTVI-1
PTVI-2
PTVI-3
PTS2
PTS3
PTS4
PTS5
PTWC-1
PTWC-2
Brief description of challenge(s)
Physical, Neurological, etc.
Adaptive equipment needed
Prosthetics, Wheelchair, Guide, etc.
Prosthetist/Medical Team
Name(s) and contact info
Travel restrictions
Personal and/or Equipment
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Lifestyle Information
All items are optional to answer, but extremely helpful
What do you do for a living?
Optional
Number of hours per week
Average
Amount of Vacation / Personal Time Off (PTO) available per year?
Average # of days
What is the activity level at your job?
Light (Primarily seated)
Moderate (a lot of walking, climbing stairs, carrying some boxes, etc.)
High (heavy labor, very active)
Type of schedule
Standard, Shiftwork, etc.
How often do you travel (work, leisure, etc.)?
NONE
Rarely
A few times a year
A few times a month
Weekly
How would you rate the stress of your job?
No or little stress
1
2
3
4
Overwhelming stress/ready to quit
5
1 is No or little stress, 5 is Overwhelming stress/ready to quit
How would you rate the stress of your lifestyle?
No or little stress
1
2
3
4
Overwhelming stress/verge of nervous breakdown
5
1 is No or little stress, 5 is Overwhelming stress/verge of nervous breakdown
Number of members in your household?
Optional
Number of members under 18 in your household?
Optional
Besides Swim, Bike & Run, what are your hobbies, or what do you like to do in your spare time?
Optional
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Triathlon Goals
All items are optional to answer, but extremely helpful
Which of the following personal goals best fit in with your goals for your training (select all that apply)?
NONE
Appearance/Aesthetics
Breathe better
Cardiovascular Endurance
Flexibility
Health (General)
Increased Endurance
Muscular Definition
Muscular Strength/Power
Self-esteem/Confidence
Speed
Sports Performance
Stress Reduction
Other
Weight Loss
Which of the following sport specific goals best fit in with your goals for your training (select all that apply)?
Improve Swim Time
Reduce Fear of Open Water
Improve Bike Time
Improve Bike Handling Skills
Improve Run Time
Improve Run Form
Improve Transition Times
Improve Nutritional Habits
Improve Hydration Habits
Other
What are the top three goals you want to accomplish, in order of importance?
Optional
Briefly explain why these three goals are most important to you.
Optional
What possible personal barriers do you feel are currently keeping you from reaching your fitness goals?
Not knowing where/how to begin
Lack of Equipment
Lack of motivation
Lack of Results
Hitting A Plateau
Self Conscious
Time available to train
Other
Money
Other
How often are you available to train per week to reach your goals?
Please Select
4-6 Hrs
6-8 Hrs
8-10 Hrs
10-15 Hrs
15+ Hrs
Scroll for more options
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Training and Exercise History
All items are optional to answer, but extremely helpful
Do you currently exercise on a regular basis?
Yes
No
If yes, how many days a week?
Average
If Yes, how long on average is a current typical workout session (in minutes)?
Optional
If Yes, briefly describe your current typical exercise routine:
Optional
Expected Exercise Availability for Triathlon Training
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Mornings
Afternoons
Evenings
All Day
Type of Exercise Availability (i.e., if unable, leave those days blank)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Swim
Bike
Run
Strength
Do you have a membership at a gym or fitness center?
Yes
No
If yes, what gym / fitness center?
Include location
Number of Triathlons completed or attempted
Longest Distance Triathlon Completed
None
Super Sprint
Sprint
Olympic
Half Iron/IM70.3
Full Iron/IM140.6
Ultra
Other
Name of Goal Race (or type of race you'd like to attempt)
Include Location and Date, if known
Triathlon Qualifications/Honors
I.e., All American, USAT Age Group ranking, IMWC/IM70.3WC qualifier, etc.
Other Past Endurance Events
I.e., Marathon(s), GranFondo, OWS, etc.
Do you have a TrainingPeaks account?
Yes
No
If Yes, email associated with TrainiingPeaks
example@example.com
Do you have a Strava account?
Yes
No
If Yes, email or username associated with Strava
example@example.com or @firstlastname3
Do you have a Garmin Connect account?
Yes
No
If Yes, email or username associated with Garmin Connect
example@example.com or @firstlastname3
Do you currently participate in any other competitive / team sports?
Yes
No
If yes, what sport(s) and how often?
Softball, Soccer, Rock Climbing, etc.
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Swim Experience
All items are optional to answer, but extremely helpful
Number of years Swim Experience
Please Select
None
Less than 1
1-2
3-5
5+
How confident of a Swimmer are you?
Not very confident
1
2
3
4
Extremely confident
5
1 is Not very confident, 5 is Extremely confident
Numbers of days per week swimming
Please Select
0
1
2
3
4
5+
Average
Distance per swim session
Please Select
0
Less than 1000
Up to 2000
2000 - 3000
3000 - 5000
5000+
Average
Swim session distance
Yards
Meters
Does your gym / fitness center have a pool?
Yes
No
If yes, what is the length of the pool (if known)?
25 Yards
25 Meters
50 Meters
Other
Other
If yes, is it indoors or outdoors?
Indoors
Outdoors
Both
Do you have access to any other pool(s)?
Yes
No
Home, etc.
Do you have access to any Open Water?
Lake
River
Ocean
Other
Other
Primary type of Open Water?
Freshwater
Saltwater
Other
Other
Swim Gear (select all that apply)
NONE
Goggles
Smart Goggles
Swim Cap
Wetsuit Full
Wetsuit Sleeveless
Neoprene Jammers
Paddles
Snorkel
OWS Safety buoy
Fins Short
Fins Long
Swim Heart Rate Monitor (HRM)
Other
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Bike Experience
All items are optional to answer, but extremely helpful
Do you have a Bike?
NO
Yes, Road Bike
Yes, Tri Bike
Yes, Mountain Bike
Yes, eBike
Yes, Other
Other
If Yes, what Brand/Make/Model/Year of Bike(s)?
Number of years Cycling Experience
Please Select
None
Less than 1
1-2
3-5
5+
How confident of a Cyclist are you?
Not very confident
1
2
3
4
Extremely confident
5
1 is Not very confident, 5 is Extremely confident
Numbers of days per week cycling
Please Select
0
1
2
3
4
5+
Average
Distance per cycling session
Please Select
0
Less than 10
Up to 20
20 - 30
30 - 50
50+
Average
Cycling session distance
Miles
Kilometers
Do you have a Bike Computer (displays and/or records speed, cadence, etc.)?
Yes
No
Not sure
If Yes, what Brand/Type of Bike Computer?
Optional
Do you have a Power Meter on your bike?
Yes
No
Not sure
If Yes, what Brand/Make/Model of Power Meter?
Optional
Access to Biking outdoors? (select all that apply)
NO
Yes, Road
Yes, Trails
Yes, Track / Velodrome
Yes, Other
Other
If Yes, what is the terrain like in your area?
Mostly flat
Small hills
Steep hills
Mountains
Mixed
Other
Other
Do you ride with a Cycling group or club?
Yes
No
If Yes, what is the name of the group or club?
If applicable
Bike Gear
NONE
Certified Helmet (CPSC/ANSI/ASTM, etc.,)
Sunglasses / Eye Protection
Bike Gloves Fingerless
Bike Gloves Full
Bike Shorts w/ chamois
Bike shoes
Clipless Pedals
Bike Jersey w/ pockets
Bike tire pump
Standard (rim) brakes
Disc (hydraulic) brakes
Spare tire / repair kit
Other
Bike Multi-tool
Other
Do you have an indoor bike trainer?
Yes
No
If Yes, is it a "Smart" or "Dumb" trainer?
Smart
Dumb
I don't know the difference
If "Smart", what Brand/Make/Model of trainer?
Optional
Do you use a Virtual Bike Training program?
Yes
No
If Yes, which one?
Bkool
FulGaz
Rouvy
TrainerDay
TrainerRoad
Wahoo RGT
Zwift
Wahoo SYSTEM
Xert
Other
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Run Experience
All items are optional to answer, but extremely helpful
Access to Running outdoors? (select all that apply)
NONE
Yes, Road
Yes, Trails
Yes, Track
Yes, Other
Other
If Yes, what is the terrain like in your area?
Mostly flat
Small hills
Steep hills
Mountains
Mixed
Other
Current Brand/Make/Model running shoe(s)?
Optional
Do you have a Sports / GPS watch?
Yes
No
Not sure
If Yes, Brand/Make/Model watch?
Optional
Other Run gear
NONE
Heart Rate Monitor (HRM)
Running hat
Sunglasses / eye protection
Running Dynamics Pod
Running Power Meter
Hydration Belt
Trail Shoes
Reflective clothing
Other
Headlamp or other night lights
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Strength Training
All items are optional to answer, but extremely helpful
Have you ever done a structured strength training routine?
Yes
No
If Yes, what kind?
Strength - Free Weights
Strength - Weight Machines
Boot camp
Kick Boxing
Crossfit
Orangetheory
Hybrid classes
Yoga
Barre
Pilates
Spin Class
Other
Have you trained One-on-One with a personal trainer before?
Yes
No
If Yes, was your previous experience positive or negative?
I hated it
1
2
3
4
I loved it!
5
1 is I hated it, 5 is I loved it!
Why?
Optional
What equipment do you have access to at home?
NONE
Aerobic Machines (Treadmill, elliptical, stationary bike, rower, etc)
Barbells
Bosu Ball
Cable Weights
Dumbbells
Kettlebells
Pilates Reformer
Punching Bag
Resistance Bands
Stability Ball
Suspension Straps (TRX, etc.)
Vasa SwimERG
Vasa Trainer
Weight Bench
Weight Machines
Other equipment
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Mental Readiness/Personality
All items are optional to answer, but extremely helpful
Please rate your mental readiness to make changes to reach your goal.
I don't want to make any changes.
1
2
3
4
I am ready to make any lifestyle changes to reach my goals!
5
1 is I don't want to make any changes. , 5 is I am ready to make any lifestyle changes to reach my goals!
Please rate your motivational level to do what it takes to reach your goal.
I like things the way they are
1
2
3
4
I am ready to make any lifestyle changes necessary to reach my goals!
5
1 is I like things the way they are, 5 is I am ready to make any lifestyle changes necessary to reach my goals!
Attitudes - select all that apply
I prefer a strong motivator to push me to exercise
I just want to be told what to do; I don't like to have to make decisions about exercise
I like to be informed about my program and how it is going to lead me to my goals
I like to try new things to discover if they are effective
I get nervous exercising around other people
I am willing to push past my comfort level to reach my goals
f I feel things are really hard I tend to back off
I need to be held accountable for what I am doing
If everybody else in the group is stronger/faster than me, I get intimidated and lose motivation
I like to workout, but I don't like to get worn out
Being sore the day after a workout tells me my workouts are working
Other
Self Assessment of Ability to Handle Challenges
Not Confident
Slightly Confident
Confident
Mostly Confident
Extremely Confident
Self-Awareness
Consistency
Ability to complete my “A” Race
Ability to set goals and targets
Ability to follow through with goals
Use of visualization/imagery to prepare for a race
Use of self-talk/thought control
Ability to pay attention/focus under stress
Ability to endure peak uncomfortability
Ability to excel under pressure
Ability to make decisions under stress
Ability to take recovery days without guilt
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AquaTerra Coaching, LLC
Waiver and Release from Liability
A check mark below indicate I have read, agree with and understand the following:
*
I have read, understood and agree to the terms outlined in the WAIVER AND RELEASE FROM LIABILITY.
I agree and verify that all of the information that I have given AquaTerra Coaching, LLC and its representatives is accurate, up-to-date, and without the omission of any known medical issues.
I agree and verify that if I have omitted any necessary personal information, whether knowingly or unknowingly, I will hold AquaTerra Coaching, LLC, its principles and representatives, harmless against all liability for any damages that may occur to myself or to others because of my actions or inactions.
I agree to keep AquaTerra Coaching, LLC apprised of any changes or upcoming changes concerning my physical health and personal information.
I understand and agree that it is my responsibility to let AquaTerra Coaching, LLC know if I find myself in any pain or discomfort before, after, or during any Activities and Events.
If I do require medical treatment or attention while or after participating in Activities and Events. I agree that the medical costs are mine and mine alone and hold AquaTerra Coaching, LLC, its principles and representatives, blameless from any charges, fees, or costs that my treatments may incur.
* I agree, and it is my intent, to electronically sign this document by e- signature. By submitting this e-document to AquaTerra Coaching, LLC in this way, I and am affirming to the truth of the information contained therein, and that I understand and agree that this e-signing and submitting is the legal equivalent of having placed my handwritten signature and affirmation on the submitted document in accordance with New York State and Federal laws.
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Last Name
Today's Date
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