FITNESS ASSESSMENT CARD

DATE:
MEMBER NO:
NAME____________________________________DOB____________ MALE/FEMALE______________
ADDRESS _____________________________________________________________________________
EMAIL ADDRESS_____________________________ SOURCE__________ COMPANY _____________

EXERCISE AND HEALTH HISTORY

HAVE YOU JOINED A FITNESS STUDIO BEFORE? YES/NO __________________________________

IF YES-IS YOUR MEMBERSHIP CURRENT? _______________________________________________

ARE YOU CURRENTLY FXERCISING? ____________________________________________________

IF YES, WHAT ACTIVITY? _______________________________________________________________

WHAT RESULT DO YOU WANT TO ACHIEVE?

HEALTH DOCTORS ADVICE / STRESS MANAGEMENT / SLEEP BETTER / INCREASE IMMUNITY

APPERANCE FIRM UP / BODY TONE / REDUCE WEIGHT / BODY FAT / BODY SHAPE / SYMMETRY / IMPROVE SELF ESTEEM

PERFORMANCE ENDURANCE / FITNESS / ENERGY LEVEL / SPORTS CONDITIONING / IMPROVE CONFIDENCE

WHICH ONE OF THE ABOVE GOALS IS MOST IMPORTANT TO YOU? ________________________

_______________________________________________________________________________________

FOR STUDIO USE ONLY

WE LIKE TO SUPPORT OUR NEW MEMBERS WITH REGULAR FOLLOW-UP CALLS
WHEN WOULD BE BEST TIME TO CALL YOU?
MORNING [ ] AFTERNOON [ ] EVENING [ ]
INSTUCTOR:
CONTACT NO:
MOVEMENT SCREEN: OVERHEAD SQUAT
LIMITED ANKLE ROM BEFORE COMPENSATION OCCURS
LIMITED KNEE ROM BEFORE COMPENSATION OCCURS

0
LIMITED HIP BEFORE COMPENSATION OCCURS

FOOT & ANKLE:

 FOOT FLATTENS (PRONATE) LEFT/RIGHT EXTERNALLY ROTATES(TURNOFF)
 LIMITED KNEE ROM IN DORSIFLEXION LEFT/RIGHT INSTABILITY IN ANKLE COMPLEX

KNEES:
 MEDIAL DEVIATION LEFT/RIGHT CORE DYSFUNCTION
 LIMITED KNEE ROM BEFORE COMPENSATION OCCURS

LUMBO-PELVIC-HIP COMPLEX:
 ASYMETRICAL WEIGHT SHIFTING LEFT/RIGHT CORE DYSFUNCTION
 LOW BACK ARCHES IN EXTENSION LOWBACK ROUNDS IN FLEXION

SHOULDER COMPLEX:
SHOULDER PROTRACTION SHOULDER ELEVATION
SHOULDER ABUCTION SCAPULAR WINGING
ARMS DROPS FROWARD

HEAD:
FORWARD HEAD POSTURE CERVICAL HYPEREXTENSION
ASYMMETRICAL HEAD SHIFTING LEFT/RIGHT

BALANCE:
GOOD BALANCE & STABILITY AVERAGE POOR BALANCE & STABILITY

SYMMETRY:
WEIGHT DISTRIBUTION DEVIATES LEFT _______________ RIGHT _________________

MEASUREMENTS:
NECK : HEIGHT :

CHEST : WEIGHT :

ARM : SLEEP :

WAIST : WATER :

HIP : WORKING NATURE :

CALF : MEDICAL ISSUES :

BF% : MEDICATIONS :

B/P :
NAME:
TRAINER NAME:
PT/GT:

FOAM ROLL CORE

MOBILIZATION BALANCE

MONDAY TUESDAY WEDNESDAY

THURSDAY FRIDAY SATRURDAY

TYPES OF POSTURE