Team MPI Athlete Questionnaire-Team MPI

First Name

Last Name

Email

Phone Number

Best Contact Time?

Address

Emergency Contact Name

Emergency Contact Number

Gender

Date of Birth

Height

Weight

T-Shirt Size (Note: female sizes run small)

Where or from whom did you hear about Team MPI?

Write Team MPI Referral Athlete's Name / Camp or Clinic / Other

What is your occupation and about how many hours a week do you work?

Medical History: Medications?

Allergies?

Significant Past and/or Current Medical History

Do you have, or have you had, any of the following? (check all that apply)

Has a doctor ever said that you have a heart condition and recommended only medically supervised physical activity?

Yes

No

Do you have chest pain brought on by physical activity?

Yes

No

Have you developed chest pain within the last month?

Yes

No

Do you tend to lose consciousness or fall over as a refult of dizziness?

Yes

No

Has a doctor ever recommended medication for high blood pressure or a heart condition?

Yes

No

Are you aware, through your own experience or a doctor's advice, of any other physical reasons against your excercising without medical supervision?

Yes

No

If yes to any of the above, please explain

Do you have any metabolic diseases, controlled or uncontrolled, such as diabetes, hyperthyroidism, hypothyroidism, etc?

Yes

No

Do you, or have you smoked regularly within the last 5 years?

Yes

No

Are you, or have you been, recently pregnant?

Yes

No

Do you have high cholesterol?

Yes

No

Have you have any surgery in the past year?

Yes

No

Have you ever had an injury that caused you to stop exercising for more than one week?

Yes

No

Are you, or have you ever been, anorexic or bulimic?

Yes

No

Are there any other physical or emotional problems that may affect your training?

Yes

No

If yes to any of the above, please explain

Please list the sports and activities in which you have participated most often throughout your life. Include duration, when and how competitive you were along with any other comments.

Please list any significant PR's in endurance sports that you think your coach should know.

On average, how many hours a week do you train?

Have you ever done any strength resistance training?

Yes

No

Do you feel you have ever "overtrained"?

Do you have any chronic injuries from any sport or activity that may flare up or should be taken into consideration in developing your training plan?

What do you feel are your strengths and weaknesses as an endurance athlete?

What is your waking pulse?

Select what you feel is your current fitness level is:

Describe your longest single training session in the last three weeks:

MONDAY: Please list your availability to train for each day of the week in hours

TUESDAY: Please list your availability to train for each day of the week in hours

WEDNESDAY: Please list your availability to train for each day of the week in hours

THURSDAY: Please list your availability to train for each day of the week in hours

FRIDAY: Please list your availability to train for each day of the week in hours

SATURDAY: Please list your availability to train for each day of the week in hours

SUNDAY: Please list your availability to train for each day of the week in hours

Please check off the equipment that you own or have access to:

If you have an indoor bike smart trainer, which software app to you use?

Other*

What are your expectations for MPI?

At the end of this season, how will you judge if the training program was successful?

Why do you train and compete in endurance sports (be honest)?

List your "A" races that you'd like to compete in for the upcoming season.

List all other races you'd like to participate in for the upcoming season.

List your goals for the season from number one down.

I hereby contract Team MPI (Multisport Performance Institute) as my personal coach for endurance sports. I agree to pay for services at the beginning of each upcoming month of training or prior to Hourly 1v1 sessions.

Performance Coaching by Mark Sortino

Hourly 1v1 Coaching by Mark Sortino

Customized Stand-Alone Coaching by Mark Soritno

Group Coaching by Mark Sortino

Team MPI Anti-Doping Policy:I understand that Team MPI has a zero-tolerance policy for doping. This is defined as an athlete taking illegal, prohibited substances listed in the WADA Prohibited List. Depending on the race event, either USADA (USAT sanctioned events for example) or WADA (Ironman sanctioned events for example) rules apply.If an athlete is known to have taken a prohibited substance by any coaching staff on Team MPI or has tested positive by any National or International drug testing organization and does not have a therapeutic use exemption (TUE) authorizing use during training or competing or both, he/she will no longer be a Team MPI athlete.I understand that it is my responsibility to know what is prohibited and what I ingest into my own body. I fully support clean sport and understand Team MPI’s zero tolerance policy.

I AGREE and understand the above statement

Your Signature

Date

In consideration for being accepted as a client by Team MPI (Multisport Performance Institute, Inc.) for the purposes of improving my fitness, I hereby attest that I am in good health, that my statements in the Athlete Questionnaire are accurate to the best of my knowledge, and that my physical condition has been verified by a licensed medical doctor. I fully understand the risk inherent in such a fitness program and accept for myself, my heirs, and my personal representatives full responsibility for personal bodily injury, death, or property losses that may occur as a result of my being a part of this program or engaging in training sessions. I hereby indemnify and save and hold harmless Mark Sortino and any other contracted coaches working under Team MPI (Multisport Performance Institute, Inc.) from any loss, liability, damage, and cost I may incur due to my participation in this program. I have read and voluntarily signed the waiver and release from liability, and further agree that no oral representations, statements, or inducements apart from the foregoing written agreement have been made. I hereby grant full permission to Team MPI (Multisport Performance Institute) to use any photographs, videotapes, motion pictures, website images, recordings or any other record of this service and to be auto-enrolled to receive the company newsletter.

I AGREE and understand the above statement

Your Signature

Date