Health questionnaire

Please complete this before your training starts. It helps us coach you safely. Your answers are confidential and handled as described in our privacy policy.

Full name Email Date of birth

1. Has a doctor ever said you have a heart condition, or that you should only do physical activity recommended by a doctor? No Yes

2. Do you feel pain or tightness in your chest during physical activity? No Yes

3. In the past month, have you had chest pain when you were not doing physical activity? No Yes

4. Do you ever lose your balance because of dizziness, or have you ever lost consciousness? No Yes

5. Do you have high blood pressure, diabetes, asthma or any other ongoing medical condition? No Yes

6. Are you currently taking any prescribed medication? No Yes

7. Do you have a bone, joint or muscle problem, or a current injury, that could be made worse by running? No Yes

8. Are you pregnant, or have you given birth in the last 12 months? No Yes

9. Do you know of any other reason why you should not take part in running training? No Yes

If you answered "yes" to anything, please give details Emergency contact (name and phone) I consent to Uphill Coach storing and using this health information to plan my training safely. I can withdraw consent at any time. My answers are true and complete. I'll tell my coach about any change in my health, and I've read the coaching terms including the medical disclaimer.

Answered "yes" to any question? Please speak to your doctor before starting training. We may ask for written clearance.

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