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Medical Record Number

Name
Age
Occupation
Hobbies

M E D I C A L F I T N E S S R EP O R T

GOAL

FITNESS TEST
INDICATOR TEST PREPROGRAM POSTPROGRAM NOTES
POSTURAL Postural Grid

UPPER EXTREMITY Hand Left Left

MUSCLE STRENGTH Dynamometer Right Right

Bench Press
LOWER EXTREMITY
Deadlift
MUSCLE STRENGTH
Squat

Sit and Reach


FLEXIBILITY
Test

MUSCLE ENDURANCE Plank

6MWT /
CARDIOVASCULAR
Ebbeling

BALANCE Stork Test

Shuttle Run /
AGILITY*
T Test

REACTION TIME* Blazepod

PT. WELSPRO INSPIRASI UTAMA


Giesmart Plaza (d/h Graha Anugerah) Mezzanine & 2nd Floor, Jl. Raya Pasar Minggu No.17A Pancoran, Jakarta Selatan 12780
DKI Jakarta E info@welspro.com W www.welspro.com P +6221-2696 66000
Medical Record Number
Name
Age
Occupation
Hobbies

SUMMARY / RECOMMENDATION

Jakarta, ____________________

___________________________

PT. WELSPRO INSPIRASI UTAMA


Giesmart Plaza (d/h Graha Anugerah) Mezzanine & 2nd Floor, Jl. Raya Pasar Minggu No.17A Pancoran, Jakarta Selatan 12780
DKI Jakarta E info@welspro.com W www.welspro.com P +6221-2696 66000

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