Client Information Form

Date

YYYY

Fitness Assessment #:

The number indicates how many fitness assessments have been completed for this client.

Name

First Name

Last Name

Email Address

Age (Years)

Male or Female?

Telephone

(###)

###

####

Resting Heart Rate (RHR)

RHR (15 sec):

Resting Blood Pressure

SBP (mmHg): / DBP (mmHg):

Waist Circumference

Waist Circumference in cm:

Weight (Kg)

Please give an accurate weight. This will be used to measure progress with weight training and nutrition

Height (cm)

Aerobic Fitness Assessment

mCaft

Treadmill Walking

One Mile Walk

Cycle Ergometer

85% Predicted Heart Rate Max

[HRmax =.85(220-age)]

Predicted VO2max:

VO2max (ml-kg-min)

Grip Strength

Right Hand 1 (kg):

Grip Strength

Left Hand 1 (kg):

Grip Strength

Right Hand 2 (kg):

Grip Strength

Left Hand 2 (kg):

Push Ups

# Completed

Sit and Reach

Trial 1 (cm):

Sit and Reach

Trial 2 (cm):

Sit and Reach

Max (cm):

Vertical Jump

Stand-reach (cm):

Vertical Jump

Jump 1 (cm):

Vertical Jump

Jump 2 (cm):

Vertical Jump

Jump 3 (cm):

Vertical Jump

Jump Height = maximum jump height - stand reach (cm):

Vertical Jump

Peak Leg Power (watts) = [(60.7 x jump height (cm) + (45.3 x body mass (kg)] - 2055 =

Back Extension

Time (seca):

One Leg Stance

Eyes Open - left (sec)

One Leg Stance

Eyes Open - right (sec)

One Leg Stance

Best Time (sec):

One Leg Stance

Eyes Closed- left (sec)

One Leg Stance

Eyes Closed - right (sec)

One Leg Stance

Best time (sec)