Cyber Cycle Coach Dave Jordaan
USA Cycling Coach
Questionnaire

By proceeding and Completing the athlete Questionaire, you confirm that you prescribe to the following ethical statement.

I believe that, as an athlete with high ethical standards, I will train and compete according to the rules and ethics of sport. I believe that athletes should avoid the use of banned substances to prevent potential health risks and I will abide by the purest rules of sport. I am an athlete who competes and trains “clean” and I know that success comes from preparation, tactics and teamwork rather than something that comes in a pill or from a needle. As such I will abide by all the rules of USA Cycling, the UCI, or the United States Olympic Committee depending on jurisdiction.

Yes, I prescribe to the ethical statement

Personal Information

Number of hours worked each week

small, medium, large

US & European if you know it

high arch, wide, etc.

Waking 3 day average for full 60-second count

Highest seen within the last 12 months

Health

If you reply yes to any question please provide details and clearances.

Have you had a physical in the last year by a licensed physician?

Were you cleared to participate in exercise programs?

Has anyone advised you to limit your exercise?

Have you or anyone in your family had heart disease/trouble or high cholesterol?

Have you ever had chest, shoulder, neck or arm pains after exercise?

Have you ever fainted, felt dizzy, or unusually winded after exercise?

Do you have high blood pressure?

Are you diabetic?

Do you have a thyroid condition?

Women: are you pregnant or have you been pregnant in the last 3 months?

Athletic History

Do you keep a training diary or log? If yes please send.

Have you ever worked with a coach? If yes please send most current Mesocycle.

Do you have access to a facility that has weights or weight machines?

Have you ever lifted weights for training?

Current Cycling Commitment (describe what you currently do)

Describe your Cycling Hydration, Energy Gel, Food Bar habits

Cycling Goals (Be as specific as possible)

Time commitment available to attain your goal (Aim for 9 to 12 hours per week).
Provide typical group rides that you can or do participate in.

What do you consider to be your strengths as a cyclist?

What do you consider to be your weaknesses as a cyclist?