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Carol Lavrich, Clinic Director ph:
301-299-8740 Trish Koch, Clinic Manager John Philbin Philbin’s, Owner ph:
301-527-0500 |
Name:
Date: Occupation:
D.O.B:________________ Medical
History: diabetes, heart disease,
hypertension, asthma/exercise induced asthma, arthritis, Height:_______________ Joint
injuries, other____________________________
Weight:_______________ Surgeries:
____________________________________________ Medications:
__________________________________________ Allergies:
_____________________________________________ |
Podiatry:Dr. Adam Spectorph:
301-589-8886 Fax: 301-589-8889 e-mail: 1aspector@comcast.net website: www.myfootdocs.com Dr. Alex Korph:
301-702-6271 Fax: 301-702-6291 e-mail: akisok15@hotmail.com Physical Therapy:Rachel MillerrachelmillerPT@hotmail.com ph:
301-881-CARE fax: 301-881-3880 Massage Therapy: Terrel Hale (301)
943-8738 |
Running History: Years running: _________________ Avg. miles/week (for last 2 months): _____________ Longest run in past month
______________ Speed work: yes/no
_____________ Average no.
of consecutive days run in past month___________ Cross
training/Weight training: yes/no ___________ Previous best times
ever:
Recent best times (within past year): 5K: _________________ (month/year) _________________ (month/year) 10K: _________________ (month/year)
_________________ (month/year) ˝
marathon: _________________ (month/year)
_________________ (month/year) full
marathon: _________________ (month/year)
_________________ (month/year) Short term
goals:___________________________ Longer term goals:____________________________ Current
running shoe (make & model): ______________________ Why used:
____________________________________________ Prescription Orthotics worn: Yes/No _____________ Other Shoe
Modifications:_____________________ How Long? _________ |
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Running Coaches:
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Chief concerns/injuries: What
do you want to learn from our experts?
Pain:__________________________
____ racing strategy Exact location: ________________________
____cross training/weight training Onset/duration:
________________________
____ running shoes/equipment Getting worse? / Aggravated by
__________________________ ____ nutrition/weight
loss Treatment: Medicine? Rest?
Physical therapy?
____injury prevention Podiatrist/orthopedic
evaluation?
Other _______________________________ I
consent to evaluation and treatment recommendations by the volunteer staff
present today. I agree to run at my
own risk and will not hold the MCRRC, Philbin’s, or any Stride Clinic staff
member liable for any accident or injury.
I do not object to having the details of my evaluation or my
photograph published in any MCRRC publication or website for the intent of
educating and helping other runners; I also understand this brief screening
is intended only to suggest possible therapies and should not replace a more
thorough in-depth evaluation by my own doctor, therapist and coach with whom
I should follow-up if problems persist. ______________________________________________ q Check box if you checked
Dislaimer Box when registering
Signature Date on the www.Signmeup.com web site
(NOTE: you still
have to sign here) |
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ASSESSMENTS: A. Treadmill
impressions: Cadence: (total foot strikes/min. –
ideal = 180 total for R & L): your cadence: _____________ Posture: good and upright/too
forward/too far back Arm
position: good forward and back/crosses body/not relaxed
Foward-tilting pelvis?
Stride length: good/too short/too long Comments: B. Gait Evaluation: Excessive pronation/excessive
supination/neutral-stable Angle and base of
gait: Comments: C. Podiatrist: Painful and problematic areas: Foot type:
Neutral/supinated/pronated/stable/rigid/flexible Limb length
discrepancy: yes/not significant Orthotics: OK/not necessary/would be
helpful
Bony abnormalities: Skin lesions/areas of excessive
pressure:
Shoe evaluation/recommendations General
comments: D. Physical
Therapy: Strength: Flexibility: Exercises/stretches to focus on: Weight training recommended: yes/no Comments: E. Running Coach: Strength: Flexibility: Exercises/stretches to focus on: Weight training recommended: yes/no Comments: Training regimens: Current Program, if any: Weekly Mileage: ___ Too many/too few (circle one)
miles for training goals ___ Too many/too few (circle one) days
per week of running ___ Too many/too few (circle one) easy
days per week ___ Too many/too few (circle one) hard
runs (defined as long run, speedwork, hill workouts or anaerobic threshold
runs) per week Speedwork/Hard Runs ___ Speedwork should/should not
(circle one) be done given current mileage and training goals ___ Speedwork is too fast/not fast
enough (circle one) given current mileage and training goals Long Runs: ___ Long runs are too long/not long
enough (circle one) for training goals and weekly mileage Cross-Training: ___ Not enough cross-training to allow
recovery given weekly mileage and training goals Recommendations: ___ Reduce/increase/keep the same
(circle one) your weekly mileage ___ Add periodization to your training
regimen (base mileage followed by strengthening followed by speedwork) ___ Avoid running too many consecutive
days per week ___ Add/Reduce (circle one) once a
week of speedwork ___ Increase/Reduce/Keep the same
(circle one) the pace of your speedwork ___ Add/Reduce (circle one) the length
of your long run once a week ___ Add more easy days for recovery ___ Make your easy days real easy,
slow down the pace of these easy runs ___ Consider using a heart rate
monitor for measuring training benefits and to focus training ___ Add cross-training __ days per
week @ ___ minutes per session ___ Anaerobic threshold runs should be
added, as follows: ___ continuous miles ___ per week @ 85% of maximum
heart rate or 30 sec/mile slower than current 10K pace ___ Hill workouts should be added once
a week as transition from mileage building to speedwork and to build
strength Drills: F. Dietician: |
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