assessmentformAssessment FormAssessment Form Current Date Time 7:00 AM7:30 AM8:00 AM8:30 AM9:00 AM9:30 AM10:00 AM10:30 AM11:00 AM11:30 AM12:00 PM12:30 PM1:00 PM1:30 PM2:00 PM2:30 PM3:00 PM3:30 PM4:00 PM4:30 PM5:00 PM5:30 PM6:00 PM Name Date of Birth Age Email Address Gender * MaleFemale Body Comp Weight (Pounds) Height (Inches) BMI Body Fat Percent Blood Pressure Alkalinity Physique Rating BMI <18.5BMI 18.5 - 25BMI 25 - 30BMI >30 Waist - Hip Ratio Circumferences Neck Chest Breast Waist Belly Button Hips Left Thigh Right Thigh Left Calf Right Calf Left Upper Arm Left Arm Flex Right Upper Arm Right Arm Flex Resting Heart Rate * Circumference Notes YMCA Step Test or VO2 Max Test YMCA Step TestVO2 Max Test YMCA Step Test Age Range Age 15 Seconds 30 Seconds 45 Seconds 60 Seconds 1 Minute 15 1 Minute 30 1 Minute 45 2 Minutes 2 Minute 15 2 Minute 30 2 Minute 45 3 Minutes Active Resting HR 60 Seconds After Active Resting HR Range YMCA Step Notes VO2 Max Test Gender MaleFemale Age Range Age Walk One Mile as quickly as possible without speed walking and record time below Minutes Seconds HR After Completion Immediately After Completion VO2 Max VO2 Range Physical Abilities Assessment Push Up Test Position ProneFrom Knees Sit Up Test Wall Squat (Min) Bicep Max Dips Plank (Min) Position ProneFrom Knees Swiss Ball Balance Position KneelingSitting Horizontal Jump Vertical Jump Physical Abilities Notes Agility Shark Skill Lower Body Instructions Purpose:Assess lower extremity agility and neuromuscular control. (Progression from the single leg squat)Position:Position client in the center box of a grid, with hands on hips and standing on one legMovement:Instruct client to hop to each box in a designated pattern, always returning to the center box.Perform one practice run through the boxes with each footPerform test twice with each foot; 4 times total (Keep track of time)Record the timesAdd 0.10 seconds for each fault Faults Non Hopping leg touches groundHands come off hipsFoot goes into wrong squareFoot does not return to center square Practice Time (Sec) Deductions Minus Time Final Practice Time (Sec) Deductions Minus Time Final Trial 1 Time (Sec) Deductions Minus Time Trial 1 (R) Trial 1 Time (Sec) Deductions Minus Time Trial 1 (L) Trial 2 Time (Sec) Deductions Minus Time Trial 2 (R) Trial 2 Time (Sec) Deductions Minus Time Trial 2 (L) Davies Test Instructions Purpose: Measures upper extremity agility and stabilizationPosition:Place two pices of tape on the floor, 36 inches apartHave client assume a push-up position, with one hand on each piece of tape Movement:Instruct client to quickly move his or hier right hand to touch the left handPerform alternating touching on each side for 15 secondsRepeat for 3 trailsReassess in the future to measure improvement of number of touchesRecord the number of lines touched by both hands Trial 1 Trial 1 Reps Trial 2 Trial 2 Reps Trial 3 Trial 3 Reps Davies Test Average HR METHODS (YMCA) Min HR Range Max HR Range HRR Target HR Level Score What Zone Clients HR Max HR METHODS (VO2 Max) Min HR Range Max HR Range HRR Target HR Level Score What Zone Clients HR Max SubmitΔ
