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A Bid Form is a document submitted by a Contractor to an owner of a construction project stating that the Contractor has reviewed the project documents and would like to submit a bid.
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Fitness Evaluation – Part 1 Medical History Test Evaluator:
Test Date:
Client:
Sex: M F
Birthdate:
Address:
Phone:
Phone: (W)
Height:
Weight:
Desired Weight:
Age:
Check all that apply: Arthritis Back pain Knee or other joint pain Shin Splints Foot Pain Muscle Pain Other Pain Light-headedness or Fainting Chest pain at rest or exertion Shortness of Breath Hernia Do you smoke or use tobacco Elevated Triglyceride Levels Elevated Cholesterol, LEVEL:
Asthma, emphysema, bronchitis High blood pressure Coronary Disease Heart Disease Any known heart problems Stroke Epilepsy Are you diabetic Hypoglycemia Are you pregnant Family history of Coronary disease before 55 History of Atherosclerotic disease before 55 Surgeries, Hospitalization Doctor's Physical, DATE:
List current medications:
85
List current supplements:
Additional Notes:
86
Fitness Evaluation – Part 2 Pulmonary Function Resting HR:
Resting BP:
Max HR:
Body Composition - Anthropometric Measurements WOMEN
Measurement (in.)
MEN
Abdomen
Right Upper Arm
Right Thigh
Abdomen
Right Forearm
Right Forearm
Measurement (in.)
Body Composition – Skinfold Test Trial 1
Trial 2
Trial 3
Chest Triceps Subscapular Suprailiac TOTAL
87
AVERAGE
% Body Fat
Flexibility Test Trial 1
Trial 2
Trial 3
BEST
RATING
Sit and Reach
3-Minute Step Test HR Before
HR After
HR 1 min After
1 Minutes Test Sit Up Test
Push Up Test
88
RATING
Fitness Evaluation – Part 3 Muscular Strength Test EXERCISE
1 RM (lbs)
Bench Press Biceps Curl Leg Curl Leg Extension Leg Press
Postural Assessments Lordosis - lower back arched inward.
Normal
Y
N
Kyphosis - upper back rounded outward.
Normal
Y
N
Scoliosis - curving of the spine to the side.
Normal
Y
N
Right shoulder
Y
N
Left shoulder
Y
N
Even
Y
N
Less than 1/4 inch
Y
N
More than 1/4 inch
Y
N
Leg Length Discrepancy
89
Daily Fitness Inventory Client Name:
Week Start Date:
Basal Metabolic Rate Calculator Activity Level
High
Medium
Low
BMR = WT x 10.8
BMR x 1.5
BMR x 1.4
BMR x 1.3
Daily Calories Required
Daily Nutritional Intake SUN Breakfast Lunch Dinner TOTAL
LOWER BODY WT Rep WT Rep WT Rep WT Rep WT Rep Squats Front Lunges Calf Raises Hip Abduction Hip Adduction Cable Hip Ext Leg Press Leg Extension Hamstring Curl
CARDIOVASCULAR WORKOUT IN MINUTES Stair Master Bicycle Treadmill Aerobics Class
95
WT
Rep
WT
Rep
Client Consent Form By signing this document, I acknowledge that I have voluntarily chosen to participate in a program of progressive physical exercise. I also acknowledge that I have been informed of the need to obtain a physician's examination and approval prior to beginning this exercise program. In signing this document, I acknowledge being informed of the strenuous nature of the program and the potential for unusual, but possible, physiological results including but not limited to abnormal blood pressure, fainting, heart attack or even death. I also understand that I may stop any training session at any time. By signing this document, I assume all risk for my health and well-being and any resultant injury or mishap that may affect my well-being or health in any way and hold harmless of any responsibility, the instructor, facility or persons involved with the program and testing procedures. Print Name:
Signature:
Date:
96
Physician's Release Form
I have examined __________________________________________________ Client's Name I have found the following: ____ The above named may participate fully in a progressive physical activity program consisting of cardiovascular, strength and flexibility training without limitation. or ____ The above named may participate in a progressive physical activity program with the following limitations: Also, Please list any medications that your patient is currently taking that may affect heart rate or blood pressure response to exercise (elevating or suppressing). If none, write “NONE". Physician's Signature
