NAME: DATE: DATE OF BIRTH:

ADDRESS:

CITY, STATE, ZIP: PHONE:

SCHOOL/AFFILIATION:

HEIGHT: WEIGHT: AGE: GENDER:

ACTIVE SPORT: ACTIVE DANCING: NON-ACTIVE:

HAND/LEG DOMINANCE: RELIGION:

TEST RAW SCORE FINAL SCORE COMMENTS/SUGGESTIONS/REMARKS

DEEP SQUAT

L
HURDLE STEP
R
L
INLINE LUNGE
R
L
SHOULDER MOBILITY
R
L
+/-
SHOULDER CLEARING TEST
R
=/-
L
ACTIVE STRAIGHT=LEG RAISEE
R
TRUNK STABILITY PUSHUP
EXTENSION CLEARING TEST +/-
L
ROTARY STABILITY
R
FLEXION CLEARING TEST +/-
TOTAL SCREEN SCORE