Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Personal Information

  • Date of Assessment

  • Client Address
  • Date of Birth

  • Email Address

  • Best Contact Number

  • How did you hear about My Ultimate Me?

Lifestyle & Fitness

  • What is your Fitness Goal?

  • Explain the specifics around your fitness goal?

  • How soon would you like to achieve this?

  • Do you think that lifestyle changes will help achieve your goals?

  • How much time (in minutes) can you allow for exercise per day?

  • How much time (in minutes) can you allow for exercise per week?

  • What is the best time for you to exercise?

  • How do you prefer to exercise?

Medical Assessment

  • Do you have any pre-existing medical conditions that would limit your ability to exercise?

  • Do you have any specific issues with joints mobility, bones or muscles that we may improve with exercise?

  • Are you currently seeing your doctor about any condition that may be affected by exercise? Gives details if yes?

  • Detail and current medicines, pills, tablets or natural supplements you are taking currently?

Physical Activity & Nutrition

  • Detail any exercise you are doing at the moment?

  • What types of exercise do you enjoy the most?

  • Any other exercise?

  • What types of exercise do you not enjoy?

  • How many meals do you eat each day?

  • How big are the portions normally?

  • How many glasses (250ml) of water do you drink each day?

  • What foods do you like the most?

  • Would you like to change you eating habits and parts of your lifestyle to assist with reaching your goals?

  • Would you like a referral to a nutritionist?

Basic Metrics

  • Resting Heart Rate BPM

  • Chest measurement (in cm)

  • Hip measurement (in cm)

  • Waist measurement (in cm)

  • Height (in cm)

  • Weight (in KG)

  • BMI - Body Mass Index

  • Overweight range BMI

  • Obese range BMI

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.