JumpStart Fitness Assessment
Name
First Name
Last Name
I prefer to be contacted via:
Email
Phonecall
Text
Other
Trainer's Name
First Name
Last Name
Physical Activity and Medical Questionnaire
Has a doctor ever said you have a heart condition and recommended only medical supervised activity?
Yes
No
Do you ever have chest pain brought on by physical activity?
Yes
No
Do you tend to lose consciousness or fall as a result of dizziness?
Yes
No
Has a doctor ever recommended medication for your blood pressure, cholesterol or a hear condition?
Yes
No
Do you have a bone or joint problem that could be aggravated by the proposed physical activity?
Yes
No
Are you aware of any other physical reason against your exercising without medical supervision?
Yes
No
Are you over the age of 65 and not accustomed to vigorous physical exercise?
Yes
No
If you have answered yes to any of the above, please answer the following:
Have you consulted your physician about increasing your physical activity and/or performing a fitness assessment?
Yes
No
If you answered no to the previous question, will you consult your physician prior to increasing your physical activity and/or performing a fitness assessment?
Yes
No
Please check off any of the following conditions or activities that may affect you:
Heart condition
Diabetes
Asthma - Uncontrolled
Short of Breath
Arthritis Bursitis
Rheumatism
Hernia
Smoker
Angina
High Blood Pressure
Sacroiliac Problems
Knee Problems
Shoulder Problems
Back Problems
Cervical - Thoracic - Lumbar
Drink Alcohol
Have you recently had surgery? If so, please specify if possible.
I certify that these statements are true and correct. I understand that a doctor's note may be requested. If a note is requested, I should not proceed with this workout until the note is received.
Signature
Measurements
Measurement
Weight
BMI
Resting Heart Rate
BF Bicep
BF Tricep
BF Subscapular
BF Suprailiac
% Body Fat
Fat Mass
Lean Mass
Neck
Chest
Bicep R/L
Waist
Hip
Upper Thigh R/L
Calf R/L
FMS
Raw Score R/L
Final Score
Y/N
Comments
Active Straight Leg Raise
Shoulder Mobility
Impingement Clearing Test
Rotary Stability
Posterior Rocking Clearing Test
Trunk Stability Pushup
Press-up Clearing Test
Hurdle Step
Incline Lunge
Deep Squat
Level 2 Assessment
Sets
Reps
Comments
Squat
Row
Push-up
Plank
"Individual"
Past
Are you currently involved in a fitness program? If so, what is your current program?
What have you done in the past to promote a healthy lifestyle?
When were you in the best shape of your life?
How did you feel at that time?
What are your primary fitness goals?
What areas of your body would you like to improve the most?
How long have you been thinking about these goals?
Why have you waited?
How high of a priority is reaching your goal?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
When would you like seeing your results?
Obstacles
What is your current plan to achieve your goal?
What is the biggest obstacle to your success?
Coaching and Nutrition
Have you ever worked with a personal trainer? If so, were you satisfied with your results?
How can I best help you to reach your goal?
Select what best describes you:
I have a full understanding of nutrition.
I understand nutrition but could use help!
I need help to understand nutrition.
Submit
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