Pre-Race Survey

Information on this survey is private and confidential, and will not be used to diagnose or treat any injuries or illnesses. This is for research purposes only. Your race number will be your number associated with this study along with initials of your name for data collection and analysis. There will be no direct identifying information associated with presentation or publication of this data in any form.

* Indicates required field

Name (First, Last) *

First

Last

Gender *

male female

Email *

Date of Birth (dd/mm/year) *

Height (in) *

Weight (lbs) *

General Training Information

Level of Competition *

List the Race or Event you are filling out this survey for. *

If other Surfaces, list below. *

If other, list below. *

Running Demographics

Years of Running *

Number of marathons run? *

Number of Ultramarathons run in last 2 years? *

Days of training per week? *

Hours per week training? *

Average pace per mile in training *

Average Miles per Week *

Longest run training for this race? *

Longest Run Ever (miles)? *

Longest time running/walking (hours) without stopping (run/walk) *

Injuries

Basic Health Questioner

Have you ever had or believe you have had a stroke or heart attack? *

Yes No

Have you ever had coronary bypass surgery or any other type of heart surgery? *

Yes No

Do you have any other cardiovascular or lung diseases? *

Yes No

Do you have a history of diabetes, thyroid, kidney or lung disease? *

Yes No

Have you ever been told that you have had an abnormal resting or exercise EKG/ECG? *

Yes No

Pain or discomfort in the chest or surrounding areas that occurs when you engage in physical activity? *

Yes No

Abnormal shortness of breath at any time? *

Yes No

Unexplained dizziness or fainting? *

Yes No

Difficulty breathing at night except in an upright position? *

Yes No

Swelling of the ankles (unrelated to injury)? *

Yes No

Heart Palpatation? *

Yes No

Pain in the legs that causes you to stop walking (not related to racing)? *

Yes No

Know heart murmur? *

Yes No

Are you pregnant or is there a possiblity that you could be pregnant? *

Yes No

Have you had a surgery or been diagnosed with any disease in the past 3 months? *

Yes No

Have you had high blood cholesterol or abnormal lipids within the last 12 months or are you taking medications to control your lipids? *

Yes No

Do you currently smoke cigarettes or have you quit within the past 6 months? *

Yes No

Has any male in your family had heart disease? *

Yes No

Has any female in your family had heart disease? *

Yes No

Have you ever been diagnosed with high blood pressure >140/90? *

Yes No

Have you ever had a fasting blood sugar level > 110 mg/dl? *

Yes No

Are you currently under any treatment for blood clots? *

Yes No

Do you have any problems with your bones, joints or muscles? *

Yes No

Do you have any back or neck problems? *

Yes No

Are there any other conditions such as mitral valve prolapse, epilepsy, rheumatic fever, asthma, cancer, anemia, hepatitis, ect... that might alter your ability to exercise? *

Yes No

Have you ever been told by a health care professional that you should not exercise? *

Yes No

During the past 6 months have you experienced any unexplained weight loss or gain? *

Yes No

Do you use any recreational drugs or alcohol? *

Yes No

If you answered yes to any of the basic health questions above, please explain below or if there are any details that were not asked please fill those in below. *

Medications

Are you taking any prescription medications? *

Yes No

Are you taking any non-prescription medications? *

Yes No

Do you use any recreational drugs or alcohol? (totally confidential) *

Yes No

If you answered yes to any of the above medication questions, will you be using any of the above substances during your race? *

Yes No

If you are taking prescription medications, please list below. *

If you are taking any non-prescription medications, please list below. *

If you are using any recreational substances please list below. *

If you are using any of these substances during the race please list below. *

Pre-race survey

Pre-Race Survey