<p> City of Dallas: Fitness Assessment Form</p><p>Name: Date: Age:</p><p>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</p><p>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.</p><p>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 </p><p>Time available: 30-45-1 hr> more Long Term: Dislikes:</p><p>Measurements Target Heart Rate Body Fat Composition Biceps: 220- ___ (age) = _____ Triceps/Chest:</p><p>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</p><p>Lateral LPHC Excessive Forward Lean View Low Back Arches Shoulder Arms Fall Forward Complex</p><p>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</p><p>Shoulders Shoulders level (horizontally) One shoulder slightly higher One shoulder markedly higher</p><p>Spine Spine Spine slightly Spine markedly Straight curved laterally curved laterally</p><p>Hips Hips level (horizontally) One hip slightly higher One hip markedly higher</p><p>Feet pointed out Feet pointed Feet pointed out markedly, Ankles straight ahead ankles sag in pronation</p><p>Neck erect, chin Neck slightly Neck markedly Neck in, head directly forward, chin forward, chin above shoulders slightly out markedly out</p><p>Upper Upper back Upper back Upper back normally rounded slightly more markedly Back rounded rounded</p><p>Trunk erect Trunk inclined slightly to rear Trunk inclined Trunk markedly to rear</p><p>Abdomen flat Abdomen Abdomen Abdomen protruding protruding and sagging</p><p>Lower Lower back Lower back Lower back Back normally slightly hollow markedly curved hollow</p><p>Final Score </p><p>Upper Crossed Syndrome Lower Crossed Syndrome Pronation Distortion Syndrome</p><p>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</p><p>LUMBAR FLEXIBILITY: Sit and Reach Test Attempt #1 Attempt #2 Attempt #3</p><p>PERFORMANCE ASSESSMENTS</p><p>Test Speed Grade Heart rate PT comment Performance Time/Mileage Completed: Cooper 12 min Run ______</p><p>Recovery Heart rate 1 Minute: ______3 Minutes: ______Or B/P after Exercise: Rockport Walk test 1 mile B/P 3:00 after Exercise:</p><p>Test Speed Grade Heart rate PT Comment 3- Minute Step Test 96 steps/min 12 inches</p><p>Endurance Tests Results Strength Tests Results/1RM Push Up Test Leg Press</p><p>Sit Up Test Chest Press Lat Pull Down</p><p>Comments and Restrictions:</p><p>PER-FRM-230 Rev 4 8/8/2014 PER-FRM-230 Rev 3 7/22/2014</p>