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Runners Biomechanical Evaluation Form
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Email
(Required)
Phone
(Required)
How did you hear about us:
Address
Street Address
Address Line 2
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State
ZIP Code
Background
What brings you here?
When did your current problems begin / how did it happen?
Pain while running?
Yes
No
If yes, what happens to the pain while running?
Increases
Decreases
Pain after running?
Yes
No
If yes, how long does it last?
<1 hour
1-2 hours
2-6 hours
>6 hours
Does anything alleviate the pain?
Medication
Rest
Stretching
Heat / Cold
Other
If Other, please explain
Past Injuries
Please Choose all that apply
Low Back Pain
Right
Left
Running Related
Illiotibial Band Syndrome
Right
Left
Running Related
Knee Pain
Right
Left
Running Related
Stress Fracture
Right
Left
Running Related
Shin Splints
Right
Left
Running Related
Compartment Syndrome
Right
Left
Running Related
Achilles Tendonitis
Right
Left
Running Related
Plantar Fasciitis
Right
Left
Running Related
Other
Right
Left
Running Related
Other, please explain
Training
Years Running:
How would you classify your level of running?
Recreational
Competitive
Volume
miles/week
days/week
months/year
Pace (min/mile):
Speed work:
Yes
No
Hill repeats:
Yes
No
Warm-up:
Yes
No
Cool-down:
Yes
No
Stretching:
Before Run
After Run
Throughout Day
Typical Racing Distance:
5/10 K
1/2 Marathon
Marathon
Ultramarathon
Triathlon
Other
Other, please explain:
What foot strike pattern do you use?
Rearfoot
Midfoot
Forefoot
Uncertain
Footwear
Shoe brand(s) / model(s):
Shoe age: (in months):
Are your shoes comfortable?
Yes
No
Orthotic / Insert:
Yes
No
If yes:
Custom
Over the counter
Heel Lift:
Left
Right
None
Running Motivations / Goals
What is your primary reason for running?
General fitness
Weight control
Stress control
Social reasons
Competition
What are your running goals? (Check all that apply)
Continue running at current level
Increase running to higher level
Compete in specific race
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:
Date
MM slash DD slash YYYY
Δ
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