Name *

First Name

Last Name

Phone *

(###)

###

####

How do you prefer Bike Body Alignment to contact you? *

Phone

E-mail

Text

Any of the above

Gender *

Male

Female

Why do you cycle?

Competition

Recreation

General Fitness

Transportation

Have you had your bike professionally fit in the past? *

Yes

No

What other activities do you participate in other than cycling?

Strength Training - Free Weights

Strength Training - CrossFit/Orange Theory

Strength Training - Machines

Stretching

Swimming

Running

Yoga

Pilates

Other

What type of bike will be assessed at this fit session?

Road

Cyclocross/Gravel

Mountain

Hybrid

Tandem

Recumbant

Tri Bike

Other

Do you have aero bars?

Yes

No

Do you wear orthotics in your daily shoes?

Yes

No

Do you wear orthotics in your cycling shoes?

Yes

No

Do you wear gloves?

Yes

No

Have you experienced problems in any of the follow areas related to cycling?

Knee Pain

Neck Pain

Shoulder Pain

Wrist/Forearm/Hand Pain or Numbness

Back Pain

Foot Pain or Numbness

Ankle Pain

Saddle-Related Pain or Numbness

Other