Breath Runner Intake and Liability Waiver Form

  • Breath Runner

    A Division of AquaTerra Coaching, LLC

  • Run Intake Form

    Required items marked with red asterisk. All others optional. You will be able to save your answers and return later if necessary.
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  • What is the best way to contact you?*
  • Format: (000) 000-0000.

  • Health and Medical

    Required items marked with red asterisk. All others optional.
  • Gender
  • Do you suffer from or have a history of:*
  • Are you under the care of a physician, chiropractor, or other health care professional at this time for any reason?*
  • Are you currently taking prescribed medications for a chronic medical condition?*
  • Has your doctor ever said you have a heart condition?*
  • Have you ever been diagnosed with another chronic medical condition (other than heart disease or high blood pressure)?*
  • Do you have any pain or issues in your:
  • Do you lose balance because of dizziness or have you lost consciousness in the last 12 months?

  • The following is an optional but important set of questions. Please choose your responses quickly and honestly.

  • Rows

  • The following questions are ranked from:

    1 = Not at all confident

    5 = Neutral / No opinion

    9 = Completely Confident

    ______________________________________

    How confident are you that you can:

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  • MOOD STATE:

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  • Dietary Concerns

    All items are optional to answer, but extremely helpful
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  • Are you on any specific food/diet plan at this time?
  • Dietary Restriction(s). Select all that apply

  • PARA ATHLETES ONLY

    All items are optional to answer, but extremely helpful
  • USAT Open Classification

  • Lifestyle Information

    All items are optional to answer, but extremely helpful
  • What is the activity level at your job?
  • How often do you travel?

  • Training and Exercise History

    All items are optional to answer, but extremely helpful
  • Do you currently exercise on a regular basis?
  • Rows
  • Rows
  • Do you have a membership at a gym or fitness center?

  • Run Training

    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)?
  • Which of the following sport specific goals best fit in with your goals for your training (select all that apply)?
  • What possible personal barriers do you feel are currently keeping you from reaching your fitness goals?
  • Longest Run Distance Completed
  • Access to Running outdoors? (select all that apply)
  • If Yes, what is the terrain like in your area?
  • Do you have a Sports / GPS watch?
  • Other Run gear
  • Do you have a TrainingPeaks account?
  • Do you have a Strava account?
  • Do you have a Garmin Connect account?

  • Strength Training

    All items are optional to answer, but extremely helpful
  • Have you ever done a structured strength training routine?
  • If Yes, what kind?
  • Have you trained One-on-One with a personal trainer before?
  • What equipment do you have access to at home?
  • Do you currently participate in any other competitive / team sports?

  • Mental Readiness/Personality

    All items are optional to answer, but extremely helpful
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  • Attitudes - select all that apply
  • Rows

  • AquaTerra Coaching, LLC

    Waiver and Release from Liability

  • A check mark below indicate I have read, agree with and understand the following:*
  • Today's Date*
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  • Should be Empty: