Running Gait Analysis Programme — Runner Intake

1. Identification

Full Name *

Phone Number *

Email Address *

Preferred Assessment Date *

Preferred Time Slot * Select a slot Morning (7am – 10am) Midday (10am – 1pm) Afternoon (1pm – 4pm) Evening (4pm – 7pm)

2. Runner Profile

Age Group * Select age group Under 18 18-30 31-40 41-50 51-60 60+

Years Running Regularly * Select Less than 1 year 1-3 years 3-5 years 5-10 years 10+ years

Target Race Distance * Select 5K 10K Half Marathon (21K) Full Marathon (42K) Ultra Marathon Not training for a race

3. Training Load

Current Avg Weekly Mileage (km) *

Longest Single Run in Last 4 Weeks (km) *

Has your mileage jumped more than 10% in the last month? *

Yes No

4. Injury History

Do you currently have pain or discomfort while running? *

Yes No

Pain Location(s) — select all that apply

Foot/Ankle Achilles Calf Shin Knee IT Band/Outer Thigh Hamstring Hip Lower Back

Running Injury in Last 12 Months? *

Yes No

Injury Type(s) — select all that apply

Stress Fracture Tendinopathy Ligament Sprain Muscle Strain Plantar Fasciitis IT Band Syndrome Runner’s Knee (PFPS) Other

5. Red Flag Screening

Chest Pain, Dizziness or Fainting During Exercise? *

Yes No

Diagnosed Heart Condition? *

Yes No

Diabetes / Thyroid Disorder / Hypertension — select all that apply

Diabetes Thyroid Disorder Hypertension None

Diagnosed Bone Health Condition (Osteoporosis / Osteopenia)? *

Yes No

Recent Menstrual Cycle Changes (if applicable)

Yes No Not applicable

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