Runners Biomechanical Evaluation Form

First Name(Required)

Last Name(Required)

Date of Birth(Required)

Email(Required)

Phone(Required)

How did you hear about us:

Background

What brings you here?

When did your current problems begin / how did it happen?

If Other, please explain

Past Injuries

Please Choose all that apply

Other, please explain

Training

Years Running:

Volume

miles/week

days/week

months/year

Pace (min/mile):

Other, please explain:

Footwear

Shoe brand(s) / model(s):

Shoe age: (in months):

Running Motivations / Goals

What is your primary reason for running?

Distance

Date

Other (please ellaborate:

*This biomechanical running evaluation is intended to provide insight into strength, coordination of mobility deficits or imbalances that may limit your ability to move/run most optimally and efficiently. The measurements evaluated during this assessment correlate to injury risk for many common running related injuries. However, this Biomechanical Evaluation is not a comprehensive Physical Therapy Assessment. If you have a condition that is beyond the scope of this running evaluation we may suggest that you consult one of our sports Physical Therapists.

Participant / Parent / Guardian Signature: