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Fitness related form.
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85
Fitness Evaluation Part 1 Medical History
Test Evaluator:
Test Date:
Client:
Sex: M F
Birthdate:
Age:
Address:
Phone:
Phone: (W)
Height:
Weight:
Desired Weight:
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 Epilepsy 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 before 55 Do you smoke or use tobacco History of Atherosclerotic disease before 55 Elevated Triglyceride Levels Surgeries, Hospitalization Elevated Cholesterol, LEVEL: Doctor's Physical, DATE:
List current medications:
86
List current supplements:
Additional Notes:
87
Fitness Evaluation Part 2 Pulmonary Function
Resting HR:
Resting BP:
Max HR:
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
Triceps
Subscapular
Suprailiac
TOTAL
88
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
1 Minutes Test
Sit Up Test
Push Up Test
89
Fitness Evaluation Part 3 Muscular Strength Test
EXERCISE
1 RM (lbs)
Bench Press
Biceps 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 Discrepancy
Even
Y
N
Less than 1/4 inch
Y
N
More than 1/4 inch
Y
N
90
Daily Fitness Inventory
Client Name:
Week Start Date:
Basal Metabolic Rate Calculator
Activity Level
High
Medium
Low
BMR = WT x 10.8
BMR x 1.5
BMR x 1.4
BMR x 1.3
Daily Calories Required
Daily Nutritional Intake
SUN
MON
TUE
WED
THU
FRI
SAT
Fat Cal Fat Cal Fat Cal Fat Cal Fat Cal Fat Cal Fat Cal Breakfast Lunch Dinner TOTAL
SUN
MON
TUE
WED
THU
FRI
SAT
Weight (Morning)
Waist Size (Inches)
Aerobics (Minutes)
Aerobic Pulse
Resting Pulse
Blood Pressure
91
Aerobic Progress
Client:
Age:
Target Heart Rate (HR):
Before
During Exercise
1 m. after
Date
Waist
WT
RHR
CAL
FAT
BP
HR
H:MM
BP
HR
BP
HR
92
Workout Room Progress Sheet 1
Client Name:
Trainer:
Date
CHEST
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
Flat Bench Press Flat Bench Flye Inclined Press Inclined Flye Pushup Hi Cable Crossover
Lo Cable Crossover
Pec Deck
BACK
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
Shrugs One Arm Row Pull Ups Back Extension Seated Row Lateral Pull Down
Pec Deck (Rear)
93
SHOULDER
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
Overhead Press Lateral Raises Front Raises
94
Workout Room Progress Sheet 2
Client Name:
Trainer:
Date
ABDOMEN
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
Upper Crunches Lower Crunches Side Crunches
ARMS
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
Biceps Curl Concentration Curl
Hammer Curl Reverse Curl Triceps Kickback Triceps Dip Lying Triceps Ext Cable Push Downs
Wrist Curls
95
LOWER BODY
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
WT
Rep
Squats Front Lunges Calf Raises Hip Abduction Hip Adduction Cable Hip Ext Leg Press Leg Extension Hamstring Curl
CARDIOVASCULAR WORKOUT IN MINUTES
Stair Master
Bicycle
Treadmill
Aerobics Class
96
Client Consent Form By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death.
I also understand that I may stop any training session at any time. By signing this document, I assume all risk for my health and well-being and any resultant injury or mishap that may affect my well-being or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures.
Print Name:
Signature:
Date:
97
Physician's Release Form
I have examined __________________________________________________
Client's Name
I have found the following:
____ The above named may participate fully in a progressive physical activity program consisting of cardiovascular, strength and flexibility training without limitation.
or
____ The above named may participate in a progressive physical activity program with the following limitations:
Also,
Please list any medications that your patient is currently taking that may affect heart rate or blood pressure response to exercise (elevating or suppressing). If none, write NONE".
Physician's Signature
Date