NASC Form

85

Fitness Evaluation Part 1 Medical History

Test Evaluator:

Test Date:

Client:

Sex: M F

Birthdate:

Age:

Address:

Phone:

Phone: (W)

Height:

Weight:

Desired Weight:

Check all that apply:

Arthritis Asthma, emphysema, bronchitis Back pain High blood pressure Knee or other joint pain Coronary Disease Shin Splints Heart Disease Foot Pain Any known heart problems Muscle Pain Stroke Other Pain Epilepsy Light-headedness or Fainting Are you diabetic Chest pain at rest or exertion Hypoglycemia Shortness of Breath Are you pregnant Hernia Family history of Coronary disease before 55 Do you smoke or use tobacco History of Atherosclerotic disease before 55 Elevated Triglyceride Levels Surgeries, Hospitalization Elevated Cholesterol, LEVEL: Doctor's Physical, DATE:

List current medications:

86

List current supplements:

Additional Notes:

87

Fitness Evaluation Part 2 Pulmonary Function

Resting HR:

Resting BP:

Max HR:

Body Composition - Anthropometric Measurements

WOMEN Measurement (in.) MEN Measurement (in.)

Abdomen

Right Upper Arm

Right Thigh

Abdomen

Right Forearm

Right Forearm

Body Composition Skinfold Test

Trial 1

Trial 2

Trial 3

AVERAGE

% Body Fat

Chest

Triceps

Subscapular

Suprailiac

TOTAL

88

Flexibility Test

Trial 1

Trial 2

Trial 3

BEST

RATING

Sit and Reach

3-Minute Step Test

HR Before

HR After

HR 1 min After

RATING

1 Minutes Test

Sit Up Test

Push Up Test

89

Fitness Evaluation Part 3 Muscular Strength Test

EXERCISE

1 RM (lbs)

Bench Press

Biceps Curl

Leg Curl

Leg Extension

Leg Press

Postural Assessments

Lordosis - lower back arched inward.

Normal

Y

N

Kyphosis - upper back rounded outward.

Normal

Y

N

Scoliosis - curving of the spine to the side.

Normal

Y

N

Right shoulder

Y

N

Left shoulder

Y

N

Leg Length Discrepancy

Even

Y

N

Less than 1/4 inch

Y

N

More than 1/4 inch

Y

N

90

Daily Fitness Inventory

Client Name:

Week Start Date:

Basal Metabolic Rate Calculator

Activity Level

High

Medium

Low

BMR = WT x 10.8

BMR x 1.5

BMR x 1.4

BMR x 1.3

Daily Calories Required

Daily Nutritional Intake

SUN

MON

TUE

WED

THU

FRI

SAT

Fat Cal Fat Cal Fat Cal Fat Cal Fat Cal Fat Cal Fat Cal Breakfast Lunch Dinner TOTAL

SUN

MON

TUE

WED

THU

FRI

SAT

Weight (Morning)

Waist Size (Inches)

Aerobics (Minutes)

Aerobic Pulse

Resting Pulse

Blood Pressure

91

Aerobic Progress

Client:

Age:

Target Heart Rate (HR):

Before

During Exercise

1 m. after

Date

Waist

WT

RHR

CAL

FAT

BP

HR

H:MM

BP

HR

BP

HR

92

Workout Room Progress Sheet 1

Client Name:

Trainer:

Date

CHEST

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

Flat Bench Press Flat Bench Flye Inclined Press Inclined Flye Pushup Hi Cable Crossover

Lo Cable Crossover

Pec Deck

BACK

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

Shrugs One Arm Row Pull Ups Back Extension Seated Row Lateral Pull Down

Pec Deck (Rear)

93

SHOULDER

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

Overhead Press Lateral Raises Front Raises

94

Workout Room Progress Sheet 2

Client Name:

Trainer:

Date

ABDOMEN

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

Upper Crunches Lower Crunches Side Crunches

ARMS

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

Biceps Curl Concentration Curl

Hammer Curl Reverse Curl Triceps Kickback Triceps Dip Lying Triceps Ext Cable Push Downs

Wrist Curls

95

LOWER BODY

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

WT

Rep

Squats Front Lunges Calf Raises Hip Abduction Hip Adduction Cable Hip Ext Leg Press Leg Extension Hamstring Curl

CARDIOVASCULAR WORKOUT IN MINUTES

Stair Master

Bicycle

Treadmill

Aerobics Class

96

Client Consent Form By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death.

I also understand that I may stop any training session at any time. By signing this document, I assume all risk for my health and well-being and any resultant injury or mishap that may affect my well-being or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures.

Print Name:

Signature:

Date:

97

Physician's Release Form

I have examined __________________________________________________

Client's Name

I have found the following:

____ The above named may participate fully in a progressive physical activity program consisting of cardiovascular, strength and flexibility training without limitation.

or

____ The above named may participate in a progressive physical activity program with the following limitations:

Also,

Please list any medications that your patient is currently taking that may affect heart rate or blood pressure response to exercise (elevating or suppressing). If none, write NONE".

Physician's Signature

Date