Fitness Center, City of Dallas

City of Dallas: Fitness Assessment Form

Name: Date: Age:

Resting Heart rate (10 seconds) ______A resting heart rate > 100 BPM will terminate further testing. You may retest in one week. If results are still contraindicating then a Physician response Form must be requested

Blood Pressure_____/_____ (A Hypertension of > 150/100 mmhg or a Hypotension of < 80/50 will terminate further testing. You may retest in one week. If results are still contraindicating then as Physician Response Form is requested.

Exercise History Goals Past Experiences Likes/Dislikes Time Availability Past/Current With Exercise Injuries Short Term: Likes: Days: M-T-W-TH-F-S-Su

Time available: 30-45-1 hr> more Long Term: Dislikes:

Measurements Target Heart Rate Body Fat Composition Biceps: 220- ___ (age) = _____ Triceps/Chest:

Chest: ____ - _____ (resting HR) = HRR SI/ Abd: Waist: HHR_____ x .60 = ____ + (RH) ____ = ______Lower Quad: end of Training Zone (60%) Hips: HHR_____ x .80 = ____ + (RH) ____ = ______Upper Sum: end of Training Zone (80%) Thigh: Target Training Zone = Weight: Height: Calve: BFC = POSTURE AND MOVEMENT ASSESSMENTS OVERHEAD SQUAT ASSESSMENT Anterior Feet Flatten/Turn Out View Knees Move Inward

Lateral LPHC Excessive Forward Lean View Low Back Arches Shoulder Arms Fall Forward Complex

PER-FRM-230 Rev 4 8/8/2014 STATIC POSTURAL ASSESSMENT Good – 10 Fair – 5 Poor – 0 Head erect, gravity line Head twisted or Head twisted or Head passes through turned slightly to turned markedly center one side to one side

Shoulders Shoulders level (horizontally) One shoulder slightly higher One shoulder markedly higher

Spine Spine Spine slightly Spine markedly Straight curved laterally curved laterally

Hips Hips level (horizontally) One hip slightly higher One hip markedly higher

Feet pointed out Feet pointed Feet pointed out markedly, Ankles straight ahead ankles sag in pronation

Neck erect, chin Neck slightly Neck markedly Neck in, head directly forward, chin forward, chin above shoulders slightly out markedly out

Upper Upper back Upper back Upper back normally rounded slightly more markedly Back rounded rounded

Trunk erect Trunk inclined slightly to rear Trunk inclined Trunk markedly to rear

Abdomen flat Abdomen Abdomen Abdomen protruding protruding and sagging

Lower Lower back Lower back Lower back Back normally slightly hollow markedly curved hollow

Final Score 

Upper Crossed Syndrome Lower Crossed Syndrome Pronation Distortion Syndrome

PER-FRM-230 Rev 4 8/8/2014 SINGLE LEG ASSESSMENT Anterior View Knees Move Inward Right: Left: PULLING ASSESSMENT PUSHING ASSESSMENT LPHC Low Back Arches LPHC Low Back Arches Shoulder Shoulders Elevate Shoulder Shoulders Elevate Complex Complex Head Head Migrates Forward Head Head Migrates Forward

LUMBAR FLEXIBILITY: Sit and Reach Test Attempt #1 Attempt #2 Attempt #3

PERFORMANCE ASSESSMENTS

Test Speed Grade Heart rate PT comment Performance Time/Mileage Completed: Cooper 12 min Run ______

Recovery Heart rate 1 Minute: ______3 Minutes: ______Or B/P after Exercise: Rockport Walk test 1 mile B/P 3:00 after Exercise:

Test Speed Grade Heart rate PT Comment 3- Minute Step Test 96 steps/min 12 inches

Endurance Tests Results Strength Tests Results/1RM Push Up Test Leg Press

Sit Up Test Chest Press Lat Pull Down

Comments and Restrictions:

PER-FRM-230 Rev 4 8/8/2014 PER-FRM-230 Rev 3 7/22/2014