1. 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