Waist ________ Hip_________

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Waist ________ Hip_________ FITNESS ASSESSMENT for Membership NAME:______________________________________________ M / F Work Building: _______________   AGE:_______ BIRTH DATE:_____________ TOP GOAL FOR JOINING:___________________________ Current Meds:______________________________________________________________________ PERSONAL MEDICALHx:_________________________________________________________________  SMOKING Hx: NS:______ S: (_______cgs/day______yrsS) ES: (yrs_______yrsq_________cgs/day_______) CAFFEINE CONSUMPTION:_________mg/DAY ACTIVITY:NONE:______LT:______1-2X/wk:______3-5x/wk:_____TYPE:___________________ STRESS:_____/65 Diet-- QUANTITY:____/18 QUALITY:_____/15 PATTERNS:_____/7 Blood Pressure? Y N Beta Blocker? Y N Date:_____________ Height: _______ Weight: ________ RBP______/______ Data Entry Date:________ 5/6 Site Skinfolds: Chest ____ ____ ____ ____ Push up: _________ Sit and Reach: ____ ____ ____ (modified) Tricep ____ ____ ____ ____ Subscapular ____ ____ ____ ____ Abdomen ____ ____ ____ ___ BMI Waist ________ Hip_________ Suprailiac ____ ____ ____ ____ BF%= Thigh ____ ____ ____ ____ Life Fitness Step Test MAX Heart Rate (220-age_____) = _______ Target (65% MAX) = VO2=____ Stage 1 (17) HR=_______ Stage 2 (26) HR=_______ Stage 3 (34) HR=_______ updated: 7/08

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