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H E

H A
E LA TL HT H A N A DN D F IF TI NT E
N SE SS S
P O
P R R FO EF SE SS IS OI N
O A
N LA SL S A CA TC ITOI N
O NG U
G IU DI E
D E

HOW TO HOW TO WORK INTRO,

1 USE THE
GUIDE

HEALTH AND
2 WITH HEALTH
CARE
PROVIDERS

FITNESS
3 LETTER TO
HEALTH CARE
PROVIDER

INFORMED

4 MEDICAL
QUESTIONNAIRE

CANCELLATION
5 ASSESSMENT

STARTING AN
6 CONSENT

YOUR

7 POLICY

8 EXERCISE
PROGRAM
PATIENT
HANDOUT
9 PRESCRIP-
TION FOR
HEALTH

FITNESS ASSESSMENT

ANYFITNESS INC

Fitness Assessment Data Sheets


Name: _________________________ Date: ___________________

Phone number (Cell, work, home):


________________________________________________________________

Date of birth: _________________ Age: ____________ Height: _______________

Resting heart rate: ______________ Resting BP: Weight: _________

Orthopedic Limitations

Circumference Measurements

Neck: ________________ Abdominal: ______________ Waist: _________________

Shoulder: _______________ Hip: _________________ Chest: ___________________

Thigh (Mid): ________________ Arm: (L) _______________ (R ): _____________


Body Composition

Percent bodyfat: _____________ Pounds of fat: ______________ Rating: _________


Muscular Endurance

Number of push-ups: ___________________ Rating: _________________


www.ExerciseIsMedicine.org

E-mail: eim@acsm.org Phone: 317-637-9200


Number of curl-ups: __________________ Rating: _________________
Flexibility (Modified Sit and Reach test) Best of three trials

Best Trial (inches): __________________ Rating: __________________

General Screening

Postural Screen: __________________________________________________________

Anterior Shoulder Flexibility: _______________________________________________

Cervical ROM: ___________________________________________________________

Resisted internal/external rotation: ___________________________________________

Full Knee extension/flexion: ________________________________________________

Single & Double knee to chest: ______________________________________________

www.ExerciseIsMedicine.org

E-mail: eim@acsm.org Phone: 317-637-9200

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