The Junxion Center, 3505 William Nicol I P.O. Box 10236, Fourways East, 2055 I 082-461-1443 l

TRAINING QUESTIONAIRE

Please fill in the below form and e-mail to to get started (or bring to the gym)

Full Name: / Date of Birth Age:
Cell Phone Number: / Area of Work:
E-Mail Address: / Area of Residence:
Heart / blood pressure / cholesterol problems?
Asthma / diabetes / epilepsy or orthopedic problems?
Any surgery or serious illness in the last 2 years?
Are you on any medication currently?
If you have answered yes any of the above please consulted with your doctor before training at Base Fit.
How many times a day do you eat meals and when?
Give examples of what you normally eat and how much.
How many times a day do you snack and when?
Give examples of you normally snack on and how much.
How many times a day do you drink liquids and when? Give examples of what you drink. Include amount of sugar in tea/coffee etc
Are you taking any supplements? Please list.
Do you smoke? How many a day?

.

SPORT BACKGROUND - SPORT & YEARS
INJURY HISTORY
CURRENT TYPICAL TRAINING WEEK
SPORT / ACTIVITY / TIMES / WEEK / INTENSITY / DURATION
SHORT TERM GOALS (3 MONTHS) / OBJECTIVES
1.
2.
3.
MID TERM GOALS (4-8 MONTHS) / OBJECTIVES
1.
2.
3.
LONG TERM GOALS (1 YEAR) / OBJECTIVES
1.
2.
3.
What physical weakness do you have when it comes to training?
What mental blocks / challenges do you experience with regards training?

(RIDERS AND OTHER ATHLETES ONLY)

EVENTS ENTERED AND FINISHED LAST SEASON
DATE / EVENT / DISTANCE / RESULT/TIME
RACE CALENDER FOR THE YEAR - INDICATE WHICH RACES ARE THE MOST IMPORTANT
What bike do you ride?
Who are your sponsors (if any)?
What are your strengths on the Enduro/MX track?
What are your weaknesses on the Enduro/MX track?

I, hereby acknowledge that whilst the exercises suggested by BaseFit have been designed and constructed to be beneficial, the use thereof constitutes a potential risk of physical injury and/or harm to the participant.

I hereby indemnify and hold harmless BaseFit and its directors, officers, employees, agents, representatives and/or nominees from and against any liability, loss, damage, claims and/or costs of whatsoever nature and howsoever arising from or connected with or incidental to my use of the exercises and/or participation in any BaseFit activity.

I acknowledge that I have read and fully understand the above declarations.

Name: ______

Date: ______