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Physical Fitness Assessment Data Sheet

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PHYSICAL FITNESS ASSESSMENT DATA SHEET

Member’s name:___________________________________ Sex: Male /Female

RESTING MEASURES

Date of birth: _____/_____/19____ Age: _______yrs


d m y

Smoking status: yes / no If yes, how many /day: _________

Physical activity level: no exercise ; low ; mod-low ; mod ; mod-high ; high ; very high
(please circle one of the above)

How many family members with cardiac heart disease before 60?:_________ after 60?: ________

Blood cholesterol level status: healthy; low risk, moderate risk, high risk
(please circle one of the above)

Any ailment/sickness/ medication which may hamper or influence your physical fitness
assessment?

If yes please list:

Resting heart rate:_______ beats/min Resting blood pressure: _______/______mmHG

Body weight:________ kg Body height : _________ (m)

Body Mass Index: _______ Waist/hip ratio: ________

Waist circumference: ________cm (navel) Hip circumference: _________cm (widest)

Skinfold measures: triceps___________ ilium____________

thigh__________TOTAL:_________

LIPOTRAK BODY COMPOSITION MEASURES

Fat weight: ________ kg Fat % :__________ %

Lean weight: _______kg Lean %:_________ %

Lipotrak impedance:_______ ohms BMI: ____________

ACTIVE MEASURES

3- min. sub max step test: _________ (recovery heart beats/min)

handgrip strength test: right hand __________kg left hand __________kg

TOTAL __________kg
1-min timed sit ups : _________reps /min 1-min timed push ups: _________reps /min

Flexibility (sit and reach): _________ (inches/cm)

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