* Required Fields

Please select which location you are submitting this form to *

Please complete to the best of your knowledge

Name *

Age *

Gender *

Male Female

Occupation

Are you primarily a runner or a walker? *

Runner Walker

General Health - Have you ever been diagnosed with any of the following conditions (select all that apply)

DiabetesHeart ConditionsRespiratory Conditions
CancerOsteoporosisRheumatoid Arthritis
Hypo/Hyper Thyroid  

Present and or recurrent running injuries (please describe):

Other previous injuries (car accidents, surgeries, fractures etc):


Running History: Please describe your typical week with respect to your training.

Mileage/Week:

Mileage/Time and Type of run (ie. Standard, Recovery, LSD, Tempo, Hills, Intervals, etc).

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday


Running Goals

3 Months:

1 Year:


Shoes (Make & Model):

How Old?

Orthotics?

Yes

No

How Old?


Other recreational activities

Specific goals for running evaluation


Where did you hear about the NCSPT running evaluation?

No shows and late cancellations (less than 24 hours) will be charged a Cancellation Fee.

I agree to the statement above.

Beddington        403.295.8590

Thorncliffe        403.275.7728