Intake FormRunning Intake Form Name*E-Mail*Contact*BackgroundWhat brings you here?When did the current problem begin?How did it happen?Do you have pain while running?YesNoif so, what happens to the pain while running?IncreasesDecreasesDo you have pain after running?YesNoif so, how long does it last?Less than 1 hour1-2hrs2-6hrs6+hrsDoes anything alleviate the problem?MedicationRestStrechingHeat/coldOther Past InjuriesLow Back PainRightLeftRunning RelatedCompartment SyndromeRightLeftRunning RelatedIliotibial band syndromeRightLeftRunning RelatedArchilles tendonitisRightLeftRunning RelatedKnee painRightLeftRunning RelatedPlantar FaciitisRightLeftRunning RelatedStress FractureRightLeftRunning RelatedOtherRightLeftRunning RelatedShin SplitsRightLeftRunning RelatedCurrrent MedicationsAspirinAdvil/Motrin/IburprofenTylenolBronchodilatorsVitamin DCalciumOthers TrainingYears RunningHow would you classify your level of running?ReacreationalCompetitiveVolumemiles/week.days/week.months/yearPacemin/mileSpeed WorkYesNoHill repeatsYesNoWarm-upYesNoCool-downYesNoStetchingBefore runAfter runThroughout dayTypical Racing Distance5-10k1/2 MarathonMarathonUltradistanceTriathlonWhat foot-strike Pattern do you use?RearfootMidfootForefootUncertainFootwearShoe brand/nameShoes agemonthsAre your shoes comfortable?YesNoOrthotic/InsertYesNoIf YesCustomOver the counterHeel LiftRightLeftNoneRunning Motivation & GoalsWhat is the primary reason you run ?General fitnessWeight controlStress ControlSocial ReasonsCompetitionWhat are your running goals?Continue running at current levelIncrease running to higher levelCompete in specific raceother
