Name: THRESIA IRA B.

LACSA 
Section: UP-BSN-A                                                                          

Fitness Assessment Form

Resting Heart Rate: 88bpm
Basic Body Composition
Height Weight (kg): 
(m): 

Initial Eval 1 Re-eval

st
2 Re-eval
nd
3 Re-eval
rd
4 Re-eval
th

BMI
*
*BMI = weight in kilogram divided by the square of the height in meter; see page 83 in your module for
classification.

Medical History
Have you ever had surgery? Yes: ___    No:✔️
If yes, please describe: _________________________
Do you have a history of falls, trauma, auto accidents, etc.? Yes: ___    No: ✔️
If yes, please describe: ___________________
Please indicate below by marking as follows: 1= present condition 2= previous condition 
__Spinal/Disc Problem __Ankle Pain __High BP
__Lower Back Pain __Shoulder Pain __Allergies
__Hip Pain __Elbow Pain __Asthma/Bronchitis
__Knee Pain __Arthritis
__Heart Condition __Diabetes
__Ankle Pain __Heart Condition
Others: ________________________________________________________________

NOTE: PLEASE FILL OUT THE INITIAL EVALUATION ONLY IN ALL TESTS.
TAKE PICTURES WHILE TAKING THE TESTS. DO WARM-UP EXERCISES BEFORE DOING THE
TESTS.

Anthropometry: Initial Eval 1 Re-eval

st
2 Re-eval
nd
3 Re-eval
rd
4 Re-eval
th

Girth
measurements
Right upper arm
Waist
Hips
Right thigh
*Measure in centimeters
 Flexibility: Trial 1 Trial 2 Trial 3 Best (inch)
Sit-and-reach test
Initial Eval 8 inch 10 inch  13 13 inch
inch
1 Re-eval
st

2 Re-eval
nd

3 Re-eval
rd

4 Re-eval
th

*Measure in inches

Partial Curl-up Repetitions

Initial Eval
1 Re-eval
st

2 Re-eval
nd

3 Re-eval
rd

4 Re-eval
th

*Count how many curl-ups you can do in one minute and write it under Repetitions.

Cardiorespiratory Endurance: 30-sec Heart Rate

3- Minute Step Test
Initial Eval
1 Re-eval
st

2 Re-eval
nd

3 Re-eval
rd

4 Re-eval
th

Agility: Trial 1 Trial 2 Trial 3 Average

Hexagon Test
Initial Eval
1 Re-eval
st

2 Re-eval
nd

3 Re-eval
rd

4 Re-eval
th

*Use a timer and record the time on each trial.

Max Muscle Power: Vertical Jump Trial 1 Trial 2 Trial 3 Best (inch)
Initial Eval
1 Re-eval
st

2 Re-eval
nd

3 Re-eval
rd

4 Re-eval
th

*Measure in inches. Record every trial then record the best of three trials.