Physical Skills Assessment Form
Please complete this form to provide information for your physical skills evaluation. Your responses help ensure a safe and effective assessment.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you had any recent injuries or medical conditions we should be aware of?
*
No recent injuries or conditions
Yes, recent injury/condition (please specify below)
If yes, please describe your recent injury or medical condition
Rate your current physical strength
*
Very Weak
1
2
3
4
5
6
7
8
9
Very Strong
10
1 is Very Weak, 10 is Very Strong
Rate your flexibility
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Rate your balance
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Rate your endurance
*
Very Low
1
2
3
4
5
6
7
8
9
Very High
10
1 is Very Low, 10 is Very High
Rate your coordination
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Please describe any physical activities or sports you regularly participate in
Are there any specific physical skills you wish to improve?
Assessor's Observations and Comments
Submit Assessment
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