Fitness Evaluation
PERSONAL INFORMATION Test Evaluator: Test Date: Client: Age: Ph: Address: Sex: M F Ph: (w) Height: Weight: Desired Weight: Birthdate:
MEDICAL CONDITIONS: Check all that apply
Arthritis Asthma, emphysema, bronchitis Back pain High blood pressure Knee or other joint pain Coronary Disease Shin Splints Heart Disease Foot Pain Any known heart problems Muscle Pain Stroke Other Pain Epliepsy Light-headedness or Fainting Are you diabetic Chest pain at rest or exertion Hypoglycemia Shortness of Breath Are you pregnant Hernia Family history of Coronary disease Do you smoke or use tobacco History of Atherosclerotic disease Elevated Triglyceride Levels Surgeries, Hospitalization Elevated Cholesterol, LEVEL: Doctor's Physical, DATE:
List current medications:
List current supplements:
Additional Notes:
PULMONARY FUNCTION
Resting HR: Resting BP: Max HR:
RESPIRATORY FUNCTION
Forced expiratory vol (1 sec) (Fev.1.0) ml Forced expiratory vital capacity (FVC) ml
BODY COMPOSITION - ANTHROPOMETRIC MEASUREMENTS
WOMEN Measurement (in.) MEN Measurement (in.) Abdomen Right Upper Arm Right Thigh Abdomen Right Forearm Right Forearm
BODY COMPOSITION - SKINFOLD TEST
Trial 1 Trial 2 Trial 3 AVERAGE % Body Fat Chest Tricep Subscapular Sprailium TOTAL
FLEXIBILITY TEST
Trial 1 Trial 2 Trial 3 BEST RATING Sit and Reach
3 MINUTE STEP TEST
HR Before HR After HR 1 min After RATING
MUSCULAR STRENGTH TEST
Exercise 1 RM (lbs) Bench Press Bicep Curl Leg Curl Leg Extension Leg Press
POSTURAL ASSESSMENTS
Lordosis - lower back arched inward. Normal Y N Kyphosis - upper back rounded outward. Normal Y N Scoliosis - curving of the spine to the side. Normal Y N Right shoulder Y N Left shoulder Y N Leg Length Even Y N Less than 1/4 inch Y N More than 1/4 inch Y N
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