NAME_____________________________________________AGE___________HEIGHT___________

What outdoor events do you run? ________________________________________________________
 

DATE___________________LOCATION_________________TIME__________WEIGHT___________

SHOES

Name of training shoe_________________________________________________Size_______________

How old is your current training shoe?_________________________years_____months_____weeks_____

How long have you used this brand?__________________________years_____months_____weeks_____

Estimate the number of miles on your shoe____________________

Estimated Sole Weardown  (new)_____1 _____2 _____3 _____4 _____5 (worn)

INJURIES

Do you have any current injuries? __________________________________________________________

____________________________________________________________________________________
 

DATE___________________LOCATION_________________TIME__________WEIGHT___________

SHOES

Name of training shoe_________________________________________________Size_______________

How old is your current training shoe?_________________________years_____months_____weeks_____

How long have you used this brand?__________________________years_____months_____weeks_____

Estimate the number of miles on your shoe____________________

Estimated Sole Weardown  (new)_____1 _____2 _____3 _____4 _____5 (worn)

INJURIES

Do you have any current injuries? __________________________________________________________

____________________________________________________________________________________
 

DATE___________________LOCATION_________________TIME__________WEIGHT___________

SHOES

Name of training shoe_________________________________________________Size_______________

How old is your current training shoe?_________________________years_____months_____weeks_____

How long have you used this brand?__________________________years_____months_____weeks_____

Estimate the number of miles on your shoe____________________

Estimated Sole Weardown  (new)_____1 _____2 _____3 _____4 _____5 (worn)

INJURIES

Do you have any current injuries? __________________________________________________________

____________________________________________________________________________________
 

ORTHOTICS

Do you use orthotics? YES______NO______. If yes, FLEXIBLE_____SEMI-RIGID_____RIGID_____

What do they correct for?_________________________________________________________________

_____________________________________________________________________________________

INJURY HISTORY

List any injuries in the last 3 months or longer that may affect your running form.
 
 
 
 
 
 
 
 
 
 
 
 

Do you have a leg length discrepancy?  YES_____NO_____.

If yes, left longer_____right longer_____cm/in_____.

Check those injuries which you have had in the last four years. If you have had the same injury multiple times then list the number of times in the blank. Also make a note if you know the specific site or bone that had a stress fracture.

R=Right L= left

R___L___ metatarsal stress fracture

R___L___ tarsal stress fracture

R___L___ tibial stress fracture

R___L___ fibular stress fracture

R___L___ femoral stress fracture

R___L___ stress fracture of vertebrae

R___L___ chronic lower leg pain ("shin splints")

R___L___ plantar fascitis

R___L___ Achilles tendonitis

R___L___ patellar tendonitis

R___L___ iliotibial band tendonitis

R___L___ patellafemoral pain

R___L___ other____________________________