"Fitness Assessment Form - the Ilan Plan"

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WWW.ILANPLAN.COM
FITNESS ASSESSMENT FORM
Name: ______________________________________________________________________________________
Date of birth: ________________________________________________________________________________
Age/Gender: ________________________________________________________________________________
Occupation: ________________________________________________________________________________
Address: ____________________________________________________________________________________
Contact number: ____________________________________________________________________________
Email: _______________________________________________________________________________________
Date: _______________________________________________________________________________________
Emergency contact details: __________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
WWW.ILANPLAN.COM
FITNESS ASSESSMENT FORM
Name: ______________________________________________________________________________________
Date of birth: ________________________________________________________________________________
Age/Gender: ________________________________________________________________________________
Occupation: ________________________________________________________________________________
Address: ____________________________________________________________________________________
Contact number: ____________________________________________________________________________
Email: _______________________________________________________________________________________
Date: _______________________________________________________________________________________
Emergency contact details: __________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Indemnity
I understand that;
As part of this assessment I will be asked questions about my medical and activity history,
and may be asked to perform a range of physical activities for the purposes of assessing
my physical fitness
I do not need to answer any questions or do anything, but the information I give or
withhold will affect the design of my programme, and the trainers cannot be held
responsible for failing to consider a condition I did not make them aware of
The trainer has no expertise in the medical field and cannot diagnose or detect any
serious medical problems and if something concerns me I should see a medical
professional
If any medical condition raises concerns about my readiness to undertake physical
training, I will be directed to a medical professional, so that they can prohibit or
recommend various kinds of training for my health and safety
All information given here is entirely confidential, and will only be divulged as necessary
for my health and safety
Signature: __________________________________________
Date: ______________________________
Assessing trainer: ___________________________________
Date: ______________________________
MEDICAL HISTORY
Do you have a current or previous history of any of the following conditions?
Comments
Hypertension Y/N _________________________
Thyroid Disorders Y/N ______________________
Previous Heart Attack Y/N _________________
Renal or Liver Disease Y/N _________________
Angina Y/N _______________________________
Osteoporosis Y/N __________________________
Claudication Y/N _________________________
Arthritis Y/N _______________________________
Heart Murmur Y/N _________________________
Back Pain Y/N _____________________________
Previous Stroke Y/N ________________________
Recent Surgery Y/N _______________________
Epilepsy Y/N ______________________________
Previous/Current Pregnancy Y/N ___________
Asthma Y/N _______________________________
Previous/Current Smoker Y/N ______________
Emphysema Y/N __________________________
Currently receiving treatment from a health
care practitioner of any kind Y/N
Chronic Bronchitis Y/N _____________________
Taking any medication that may affect your
Diabetes Y/N _____________________________
exercise program Y/N _____________________
MUSCULOSKELETAL
History of joint sprains, broken bones, torn muscles or ligaments, ongoing pains, etc
Comments
Feet/Toes Y/N _____________________________
Middle Back Y/N __________________________
Ankles Y/N ________________________________
Neck Y/N _________________________________
Lower Leg Y/N ____________________________
Shoulder Y/N ______________________________
Knees Y/N ________________________________
Upper Arm Y/N ____________________________
Upper Leg Y/N ____________________________
Elbow Y/N ________________________________
Pelvis/Hips Y/N ____________________________
Forearm Y/N ______________________________
Lower Back Y/N ___________________________
Wrist/fingers Y/N ___________________________
ACTIVITY HISTORY
Current and previous physical activity, sport, work, etc. Note activity, its frequency, intensity, how
long it was done for, and any comments.
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
4. ___________________________________________________________________________________________
GOALS
What do you want to achieve from a programme of physical training?
Specific measurements and in what timeframe:
1. ___________________________________________________________________________________________
2. ___________________________________________________________________________________________
3. ___________________________________________________________________________________________
Availability days-times-duration:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PREFERRED/AVOIDED ACTIVITIES
Blood pressure: ______________________________________________________________________________
Resting Heart Rate: __________________________________________________________________________
Weight: _____________________________________________________________________________________
Height: ______________________________________________________________________________________
Girths: _______________________________________________________________________________________
Neck: _______________________________________________________________________________________
Chest: ______________________________________________________________________________________
Waist: _______________________________________________________________________________________
Hips: ________________________________________________________________________________________
Upper Arm: __________________________________________________________________________________
Forearm: ____________________________________________________________________________________
Thigh: _______________________________________________________________________________________
Calf: ________________________________________________________________________________________
POSTURAL ASSESSMENT
Static, Anterior/Posterior/Lateral
• Head
• Hips
• Shoulders
• Weight Shift
• Thoracic Kyphosis
• Knees
• Scapulae
• Patella
• Arm Rotation
• Achilles Tendon
• Arm-Body Gap
• Feet
• Lumbar Lordosis
• Arches
DYNAMIC, SHOULDER FLEXION-EXTENSION,
ABDUCTION/ADDUCTION
• Arms ______________________________________________________________________________________
• Head _____________________________________________________________________________________
• Scapulae _________________________________________________________________________________
• Lumbar spine ______________________________________________________________________________
TRUNK LATERAL FLEXION
• Arms ______________________________________________________________________________________
• Spine Restrict ______________________________________________________________________________
SQUAT
• Lumbar Spine ______________________________________________________________________________
• Spine Vertical Alignment ___________________________________________________________________
• Weight Shift _______________________________________________________________________________
• Hips _______________________________________________________________________________________
• Knees _____________________________________________________________________________________
• Ankles/Foot _______________________________________________________________________________
SINGLE LEG SQUAT, RIGHT
• Lumbar Spine ______________________________________________________________________________
• Spine Vertical Alignment ___________________________________________________________________
• Weight Shift _______________________________________________________________________________
• Hips _______________________________________________________________________________________
• Knees _____________________________________________________________________________________
• Ankles/Foot _______________________________________________________________________________
SINGLE LEG SQUAT, LEFT
• Lumbar Spine ______________________________________________________________________________
• Spine Vertical Alignment ___________________________________________________________________
• Weight Shift _______________________________________________________________________________
• Hips _______________________________________________________________________________________
• Knees ____________________________________________________________________________________
• Ankles/Foot _______________________________________________________________________________