STEVE LEHMAN TOURS, Ltd
Pre-Coaching Questionnaire / Athlete Waiver and Release Form
Personal Information
Name_______________________________________________________________________
Street_______________________________________________________________________
City______________________________________________State_______ZIP____________
Birthday ___/___/_____ Age________Weight_____________ Height_______________
E-mail address: ________________________________________________
Phone: Home (___)__________________ Work (___)__________________
Cell phone ( )_______________ FAX ( )_______________________
At which number should you be contacted? Home___ Work___ Cell Phone____
Best time of day to reach you? _____________________________________
Personal Information
Occupation __________________________ Hours worked weekly _________
Married? __Yes __No Spouse's Name________________
Health History
Please explain in detail on a separate sheet of paper any "yes" answer.
1. Do you know your resting heart rate?__Y__N What is it?________
2. Have you or anyone in your family had coronary artery disease? __Y __N
3. Do you ever have chest, shoulder, neck, or arm pains after exercise? __Y __N
4. Have you ever fainted, felt dizzy, or unusually winded after exercise? __Y __N
5. Has a doctor said that your blood pressure is too high or uncontrolled? __Y __N
6. Has a doctor ever said you have heart trouble, a heart murmur, or that you have had a heart
attack?___Y___N
7. Are you diabetic, have a thyroid condition, or any chronic condition. __Y __N
8. Are you using any medications? __Y__N List________________________
9. Is your cholesterol level high? __Y__N What's your cholesterol count?_______________
10. Have you ever had a complete physical exam including stress test? When? __________
11. Do you have any condition that a doctor says may limit your exercise? __Y __N
12. Have you ever smoked? __Y__N W hen did you quit? ___________
13. Have you ever had a joint or back disorder or any current injury? __Y __N
14. Have you had surgery in last 12 months? __Y __N
15. Do you have any other medical conditions you have that we should know about?
Athletic History
1. List your favorite sports and years of participation.
Sport Years Comments / Accomplishments
2. Your strength training. Type: __Nautilus __Universal Gym __Free weights __None
Briefly describe your current routine (days per week, sets, reps, resistance).
3. Have you ever had an exercise-related injury that caused you to stop exercising for a week or more? If
yes, please describe( If you’re like me please use a separate piece of paper).
4. List your best cycling results.
Section 4: Current Training Information
1. W hat are your three most important long-term goals for cycling? Please rank them 1-2-3.
1.
2.
3.
2. At the completion of our first season together, how will we know if we were successful? What is the
single most-important first-year goal we must accomplish?
3. What is your training week like now?
Day Type of workout How long How hard (lo-med-hi)
4. What is the longest workout you completed in the last 3 weeks?
Duration/Distance:_______ Type:___________
5. How many weekly hours do you have available to train? _______________
Miscellaneous Training Information
1. Do you own a heart rate monitor, cycle computer, cadence counter? ___Y ___N
2. What's the highest heart rate you've ever noticed during exercise? ____________
3. Do you know your lactate/anaerobic threshold (AT) heart rate or power level for any sport? If yes, what
is it?
4. What type of test did you undertake to determine it? _____________________________________
Diet
1. What do you eat during a normal weekday?
• Breakfast
• Lunch
• Dinner
• Snacks
Proficiencies Profile
Please circle either Agree or Disagree in response to each question.
1. I’m quite lean compared with others in my age group and category. Agree/Disagree
2. I’m more muscular and have greater total body strength than most others in my age group and
category. Agree/Disagree
3. I’m usually capable of single-handedly bridging gaps that take several minutes. Agree/Disagree
4. I’m capable of enduring relentless suffering for long periods of time, perhaps even up to one hour.
Agree/Disagree
5. I can climb long hills out of the saddle with most others in my category. Agree/Disagree
6. I can hop and jump my bike better than most. Agree/Disagree
7. I can spin at cadences in excess of 130rpm without difficulty. Agree/Disagree
8. I look forward to the climbs in races and hard group workouts. Agree/Disagree
9. I’m comfortable in an aerodynamic position that emphasizes the use of aero bars and encourages a flat
back. Agree/Disagree
10. I have a lot of fast-twitch muscles based on my instantaneous sprint speed, vertical jump or other
indicators. Agree/Disagree
11. While I suffer, I never "blow up" on climbs, even when the tempo increases. Agree/Disagree
12. In a race, I can ride near my lactate threshold for long periods of time. Agree/Disagree
13. In an individual time trial I can stay seated for the entire race. Agree/Disagree
14. In a field sprint, I feel aggressive and physically capable of winning. Agree/Disagree
15. When standing on a climb, I feel light and nimble on the pedals. Agree/Disagree
Natural Abilities Profile
Please circle either Agree or Disagree in response to each question.
1. I prefer to ride in a bigger gear with a lower cadence than most of my regular training partners.
Agree/Disagree
2. I ride best in criteriums and short road races (less than 50miles). Agree/Disagree
3. I’m good at sprinting. Agree/Disagree
4. I’m stronger at the end of long workouts than my training partners. Agree/Disagree
5. I can squat and leg press more weight than most others in my category or age. Agree/Disagree
6. I prefer long races (greater than 50 miles). Agree/Disagree
7. I use longer crank arms than most others my height. Agree/Disagree
8. I get stronger as a stage race or high volume training week progresses. Agree/Disagree
9. I comfortably use smaller gears with higher cadence than most of my regular training partners.
Agree/Disagree
10. I have always been physically quicker than most other people for any sport in which I’ve participated.
Agree/Disagree
11. In most sports, I’ve been able to finish stronger than most others. Agree/Disagree
12. I’ve always been physically stronger than most others I’ve played sports with. Agree/Disagree
13. I climb best when seated. Agree/Disagree
14. I prefer workouts that are short but fast. Agree/Disagree
15. I’m confident in my endurance at the start of long races. Agree/Disagree
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CUSTOM COACHING through STEVE LEHMAN TOURS, LTD.
ATHLETE WAIVER AND RELEASE
I acknowledge that training for and/or participating in a bicycle event is an extreme test of a person'sphysical and mental limits and such training or participation poses potential risks of serious bodily injury,death, or property damage. With full understanding of the risks I am taking, I HEREBY ASSUME ALL THE RISKS OF TRAINING FOR AND PARTICIPATING IN SUCH EVENTS and agree to the following (initial statement to which you agree at the "Init" space; parent or guardian should initial if athlete is under 18):
(Init) ___ Steve Lehman Tours, Ltd. has been retained to assist me in the improvement of my fitness.
(Init)____ I hereby attest that I am in good health and my physical condition has been verified by a licensed medical doctor.
(Init)____ In consideration of being accepted as a client by Steve Lehman Tours, Ltd., I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns, or anyone else who might claim or sue on my behalf: (a) I WAIVE, RELEASE, AND DISCHARGE from any and all claims, costs, or liabilities for death, personal injury or damages of any kind, which arise out of or relate to my training for or participation in a bicycling event, THE FOLLOWING PERSONS OR ENTITIES: Steven R. Lehman; the employees, coaches, consultants, and agents of any of the above (collectively, "Steve Lehman Tours, Ltd."); (b) I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims, costs or liabilities that I have waived, released or discharged herein; and (c) I INDEMNIFY, DEFEND, and HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions except those resulting from the willful acts or gross negligence of Steve Lehman Tours, Ltd.
(Init) ___ I AFFIRM THAT I AM EIGHTEEN (18) YEARS OF AGE OR OLDER, I HAVE READ THIS
DOCUMENT AND UNDERSTAND ITS CONTENTS.
Printed Name: _______________________________
Signature: ___________________________________ Date: _____________
Parent or Guardian’s Printed Name (if athlete is under 18): _______________________________
Signature of Parent or Guardian: ___________________________________ Date: _____________
Steve Lehman Tours, Ltd.
648 West Spring Street
Fleetwood, PA 19522
Phone: (610) 944-7885
email: steve@stevelehmantours.com
Website: www.stevelehmantours.com