A – Personal information *

Name and surname:    Birthdate:    Age:    Sex: MaleFemale    Blood type:    RH:    Weight:    Height:    Email:    Home:    Phone:   

B – Medical history

Indicate if you have suffered or not, some of the following conditions:

Frequent ear infections  Yes No         Heart problems  Yes No         Seizures   Yes No         Diabetes  Yes No
Difficulty to heal  Yes No         Hypertension Yes No         Psychiatric treatment Yes No         Mononucleosis  Yes No
Frequent nosebleeds  Yes No         Sleepwalking Yes No         Urinary incontinence Yes No         Lechina  Yes No
Measles Yes No         Rubella Yes No         Hepatitis Yes No         Mental Retardation Yes No         Motor Paralysis Yes No
Asthma Yes No         Any other

Specify if you have had allergies to any of the following medications:

Atamel, tempra, tachipirin  Yes No
Novalcina , bral Yes No
Baralcina, Buscapina Yes No
Penicillins (Pronapen, Benzetacil) Yes No
Ibuprofen, Motrin, Brugesic, Fernicaps  Yes No
Amoxicillin, Amoxal, Amitrexyl Yes No
Ampem, Ampicillin, Alampen Yes No
Bidroxil, Cedroxim  Yes No
Cefalecin,  Keforal  Yes No
Staph, Sistalcin Yes No
Iodine, Merthiolate, Povidine  Yes No
Any other medicine or food

C – Medical treatments:
Indicate if you should receive any type of medication while you are training. If yes, indicate which
Do not forget to always take to the place of training or competition the medicines you should receive.
Treatment for: Name and dose of medication

D – Presence of injuries:
Are you currently suffering from an injury that prevents you from walking or running properly? Yes No If yes, which injury?
Are you under medical and physiotherapeutic control?  Yes No If yes, which specialist assists you? Tel
In case of emergency, call:

E – Athletic background and sports information:
Number of years practicing athletics
Best time in 5 km
Best time in 10 km
Best time in Half marathon
Best time in Marathon
Better times in other distances
Maximum days training per week
Maximum kilometers traveled per week
Maximum number of kilometers reached in a training session
Instead of running, what other aerobic activity do you perform during the week?
What other sports do you practice?
Do you usually take rest days?    If so, how many?
Do you usually drink hydration before, during and after training?    If so, which one?
Do you eat any food before and after training?     If so, what and how much?
What are your available hours to train?