PHYSICAL FITNESS ASSESSMENT DATA SHEET

Members name:___________________________________ Sex: Male /Female RESTING MEASURES Date of birth: _____/_____/19____ d m y Smoking status: yes / no Age: _______yrs If yes, how many /day: _________

Physical activity level: no exercise ; low ; mod-low ; mod ; mod-high ; high ; very high (please circle one of the above) How many family members with cardiac heart disease before 60?:_________ after 60?: ________ Blood cholesterol level status: healthy; low risk, moderate risk, high risk (please circle one of the above) Any ailment/sickness/ medication which may hamper or influence your physical fitness assessment? If yes please list: Resting heart rate:_______ beats/min Body weight:________ kg Body Mass Index: _______ Resting blood pressure: _______/______mmHG

Body height : _________ (m) Waist/hip ratio: ________ Hip circumference: _________cm (widest)

Waist circumference: ________cm (navel)

Skinfold measures: triceps___________ ilium____________ thigh__________TOTAL:_________ LIPOTRAK BODY COMPOSITION MEASURES Fat weight: ________ kg Lean weight: _______kg Lipotrak impedance:_______ ohms Fat % :__________ % Lean %:_________ % BMI: ____________ ACTIVE MEASURES 3- min. sub max step test: _________ (recovery heart beats/min) handgrip strength test: right hand __________kg TOTAL 1-min timed sit ups : _________reps /min left hand __________kg

__________kg 1-min timed push ups: _________reps /min

Flexibility (sit and reach): _________ (inches/cm)