Body Mind Conditioning

Fitness Assessment

• Conducted on

  Date

• Clients Name:

• E-Mail:

• Ph No:

• Assessment Conducted By:

• Location
  Address

Medical Information

Please answer all questions from the responses received from your client if yes then ask for details and record:

• Do you suffer from back pain ? If yes please explain?

  Yes

  No

  N/A

• Are you sensitive to touch/pressure in any area ? If yes please explain?

  Yes

  No

  N/A

• Do you have tension or soreness in any specific area? If yes please explain?

  Yes

  No

  N/A

• Do you have numbness or stabbing pains anywhere?

  Yes

  No

  N/A

• Do you have numbness or stabbing pains anywhere?

  Yes

  No

  N/A

• Are You pregnant?

  Yes

  No

  N/A

• Do you have high blood pressure?

  Yes

  No

  N/A

• Do you have high cholesterol?

  Yes

  No

  N/A

• Are you epileptic?

  Yes

  No

  N/A

• Have you ever had surgery or medical procedure?

  Yes

  No

  N/A

• Have you ever broken any bones?

  Yes

  No

  N/A

• Do you experience stiff, swollen or painful joints?

  Yes

  No

  N/A

• Do you have difficulty sleeping?

  Yes

  No

  N/A

• Do you experience fatigue or lack of energy?

  Yes

  No

  N/A

• Do you experience cold hands or feet?

  Yes

  No

  N/A

• Have you ever been told by a Doctor to avoid any type of exercise?

  Yes

  No

  N/A

• Have you ever been knocked unconscious or suffered concussion?<br>If yes, please state how, how many times and the dates?

  Yes

  No

  N/A

• Do you (or someone in your family) have a cardiac condition?

  Yes

  No

  N/A

• Do you have any allergies?

  Yes

  No

  N/A

• Have you ever seen a Nutritionist/Registered Dietician?

  Yes

  No

  N/A

• Do you smoke?

  Yes

  No

  N/A

• Have you smoked in the past?

  Yes

  No

  N/A

• Do you live with a smoker?

  Yes

  No

  N/A

• Do you have any current injuries?

  Yes

  No

  N/A

• Upper Limb:<br>Any pins and needles or numbness?

  Yes

  No

  N/A

• Upper Limb:<br>Do you get any strong pain while doing everyday simple tasks (Not sport)?

  Yes

  No

  N/A

• Upper Limb:<br>Do you ever feel your shoulder give a big "clunk" or "pop out of it's socket?

  Yes

  No

  N/A

• Upper Limb:<br>Do you suddenly ever loose strength in your arm for no reason, with or without pain?

  Yes

  No

  N/A

• Lower Limb:<br>Any pins and needles or numbness or strange weakness in your leg?

  Yes

  No

  N/A

• Lower Limb:<br>Do you get any strong pain while doing everyday simple tasks (Not sport)?

  Yes

  No

  N/A

• Lower Limb:<br>Do your leg ever give way or feel unstable for any reason?

  Yes

  No

  N/A

• Lower Limb:<br>Has your problem spread to other parts of your body?

  Yes

  No

  N/A

• Spine:<br>Any pins and needles or numbness or strange weakness anywhere in the limbs, around the face of pelvis?

  Yes

  No

  N/A

• Spine:<br>Have you had within the last six weeks, or do you currently get, any strong pain in your spine (or headaches)?

  Yes

  No

  N/A

• Spine:<br>Do you get any pain with coughing or breathing deeply?

  Yes

  No

  N/A

• Spine:<br>Have you had pain in your spine for mare than six months, despite exercising weekly?

  Yes

  No

  N/A

• Do you have any current injuries?

  Yes

  No

  N/A

• What are your injuries ?

  Yes

  No

  N/A

• When is the pain the worst?

• What previous treatment(s) have you had/tried?

• Are you taking any medication? If so what are you taking?

  Yes

  No

  N/A

• Have you ever had any of the following - physical therapy, chiropractic, massage, acupuncture, Other?<br>

  Yes

  No

  N/A

• Do you drink coffee? How many cups per day ?

  Yes

  No

  N/A

• How many hours do you spend in front of a computer?

• Do you have an ergonomically set up desk/work station?

• What time do you go to bed at night?

• What time do you get up in the morning?

• How much time do you spend in the seated position in a day?

• How many meals do you eat each day? List the number and time of the day usually eaten.

• On a scale of 1 to 10 (1=No stress, 10=a lot of stress), please rate the amount of stress in your career.

• On a scale of 1 to 10 (1=No stress, 10=a lot of stress), please rate the amount of stress in your personal life?

• How many days do you have to commit towards working out?

• Is there any area of your body that you want to specifically work on?

• BP, Weight, Height and BMI.

  Yes

  No

• Details:

• Measurements:<br>Biceps, Chest, Waist, Hips, Thighs and Calves.

  Yes

  No

• Details:

• NOTES:

• Clients Signature:

  Sign

• Clients Photo

  Media

• Assessors Signature:

  Sign

• Date and time of Assessment

  Date