Please be honest when answering
questions. This test will be retaken after 12-24 months to show progress in fitness and
overall body condition as a result of your training program. Results are for your benefit
and will only be viewed by the Instructor and/or Senior student administering the tests.
Member Name:
___________________________________________________________ Telephone: ( _____
)__________________
Address:
____________________________________________________________________________________________________
City: ___________________________________ State: _______________ Zip Code:
_____________________
Sex______ Date of Birth: ______/______/______ Age_____ Weight______ Height_______ Single
or Married___________________
GENERAL BODY CONDITION
Do you use alcohol?____ How much/How
often?____________________________________________________________________
Do you use drugs?______ How much/How
often?____________________________________________________________________
Do you smoke cigarette, or have you quit recently?_____ How much/How
often?_________________________________________
How would you describe your eating
habits?_______________________________________________________________________
How many hours do you sleep a day?_____ How many hours do you work a day?_____ How much
time do you exercise?_________
GENERAL FITNESS CONDITION
Heart Rate Test
Actual resting (minimum) heart rate:_________ Actual heart rate after 5 minutes of
moderate exercise:__________
Resting (minimum)heart rate:__________ Maximum heart rate:_________Target heart
rate:__________
Manually Calculate your Maximum Heart Rate (MHR) and Training Zone (beats per minute):
1. Calculate your MHR: Subtract your age from 220.
2. Calculate 60% of your MHR: (220 - your age) X 0.6 = minimum training heart rate
3. Calculate 80% of your MHR: (220 - your age) X 0.8 = maximum training heart rate
Fitness Test Results
Test #1________ Test #2________ Test #3_________
FITNESS TEST
Test #1-Upper Body
Do as many complete, correct push-ups as you can. Women may do the modified version on
knees.
Ratings
Number
High
25
Average
15
Below Average 5
Low
Less Than 5
Test #2-Middle Body
With your hands behind your head, maintain the 45-degree angle for as long as you can.
Avoid undue stress on your neck.
Ratings
Seconds
High
25
Average
15
Below Average 5
Low
Less Than 5
Test #3-Lower Body
Lean your back against a wall and bend your legs at a bit more than 90 degrees. Hold for
as long as you can.
Ratings
Seconds
High
90
Average
60
Below Average 30
Low
Less Than 3
About the Ratings
Ratings are for men in their 20's.
Women's average will be 20 percent to 25 percent lower than men's average.
Values will decline by about 15 percent every 10 years; for example, ratings for people in
their 30's will be 15 percent less than those for 20-year-olds; ratings for people in
their 40's will be 30 percent less, and so on
Flexibility Test
Result #1_____ Result #2_____ Result #3_____
FLEXIBILITY TEST
Place a yardstick on the floor with the zero mark closest to you. Tape the yardstick to
the floor at the 15-inch mark. Have a friend help keep your legs straight during the test
but not interfere with your movements. Sit on the floor with the yardstick between your
extended legs, feet about 10 inches apart and heels at the 15-inch mark. Place one hand
over the other with one middle finger on top of the other. Slowly stretch forward without
jerking or bouncing, and slide your fingertips along the yardstick as far as possible. Do
the test three times. Your score is the highest number you reach, to the nearest inch
Men's Score by Age
20-29 30-39
40-49
50-59
60+
High
19 and up 18 and up 17 and up
16 and up 15 and up
Average
13-18 18 and up
17 and up 10-15
9-14
Below Average 10-12
12-17
11-16
7-9
6-8
Low
9 or less 11 or less
10 or less 6 or less
5 or less
Women's Score by Age
20-29 30-39
40-49
50-59
60+
High
22 and up 21 and up 20 and up 19 and
up 18 and up
Average
16-21 15-20
14-19
13-18
18 and up
Below Average 13-15
12-14
11-13
10-12
12-17
Low
12 or less 11 or less 10
or less 9 or less
11 or less
Waist size in inches:_____ Hip size in inches:______ Arm size in inches:_____ Chest size
in inches:_______ Thigh size in inches:______
How would you describe your
health?_____________________________________________________________________________
____________________________________________________________________________________________________________
Do you suffer from any stress-related symptoms?
Extreme nervousness:____ Problems sleeping:____ Problems maintaining weight:___ A
consistently high resting heart rate:_____
Have you experienced any of the following symptoms in the past months?
Chest pains when physically inactive or when physically active_________
Shortness of breath when climbing a flight of stairs_________
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