Fitness Evaluation Part 1

Medical History
Test Evaluator:

Test Date:

Client:

Sex: M F

Birthdate:

Address:

Phone:

Phone: (W)

Height:

Weight:

Desired Weight:

Age:

Check all that apply:

Arthritis
Back pain
Knee or other joint pain
Shin Splints
Foot Pain
Muscle Pain
Other Pain
Light-headedness or Fainting
Chest pain at rest or exertion
Shortness of Breath
Hernia
Do you smoke or use tobacco
Elevated Triglyceride Levels
Elevated Cholesterol, LEVEL:

Asthma, emphysema, bronchitis

High blood pressure
Coronary Disease
Heart Disease
Any known heart problems
Stroke
Epilepsy
Are you diabetic
Hypoglycemia
Are you pregnant
Family history of Coronary disease before 55
History of Atherosclerotic disease before 55
Surgeries, Hospitalization
Doctor's Physical, DATE:

List current medications:

85

List current supplements:

Additional Notes:

86

Fitness Evaluation Part 2

Pulmonary Function
Resting HR:

Resting BP:

Max HR:

Body Composition - Anthropometric Measurements

WOMEN

Measurement (in.)

MEN

Abdomen

Right Upper Arm

Right Thigh

Abdomen

Right Forearm

Right Forearm

Measurement (in.)

Body Composition Skinfold Test

Trial 1

Trial 2

Trial 3

Chest
Triceps
Subscapular
Suprailiac
TOTAL

87

AVERAGE

% Body Fat

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

1 Minutes Test
Sit Up Test

Push Up Test

88

RATING

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

Kyphosis - upper back rounded outward.

Normal

Scoliosis - curving of the spine to the side.

Normal

Right shoulder

Left shoulder

Even

Less than 1/4 inch

More than 1/4 inch

Leg Length Discrepancy

89

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
Breakfast
Lunch
Dinner
TOTAL

Fat

Cal

SUN

MON
Fat

Cal

MON

TUE
Fat

Cal

WED
Fat

TUE

Cal

WED

Weight
(Morning)
Waist Size
(Inches)
Aerobics
(Minutes)
Aerobic
Pulse
Resting
Pulse
Blood
Pressure

90

THU
Fat

Cal

THU

FRI
Fat

SAT
Cal

FRI

Fat

Cal

SAT

Aerobic Progress

Client:

Age:

Before
Date

Waist

WT

RHR

CAL

FAT

BP

91

HR

Target Heart Rate (HR):

During Exercise
H:MM

BP

HR

1 m. after
BP

HR

Workout Room Progress Sheet 1

Client Name:

Trainer:

Date

CHEST
WT Rep WT Rep WT Rep WT Rep WT Rep

WT

Rep

WT

Rep

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

Shrugs
One Arm Row
Pull Ups
Back Extension
Seated Row
Lateral Pull
Down
Pec Deck (Rear)

92

SHOULDER
WT Rep WT Rep WT Rep WT Rep WT Rep
Overhead Press
Lateral Raises
Front Raises

93

WT

Rep

WT

Rep

Workout Room Progress Sheet 2

Client Name:

Trainer:

Date

ABDOMEN
WT Rep WT Rep WT Rep WT Rep WT Rep

WT

Rep

WT

Rep

WT Rep WT Rep WT Rep WT Rep WT Rep

WT

Rep

WT

Rep

Upper Crunches
Lower Crunches
Side Crunches

ARMS

Biceps Curl
Concentration
Curl
Hammer Curl
Reverse Curl
Triceps Kickback
Triceps Dip
Lying Triceps Ext
Cable Push
Downs
Wrist Curls

94

LOWER BODY
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

95

WT

Rep

WT

Rep

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:

96

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

97