ONLINE DATA INPUT / BODY AGE FIT-TEST

All you Need is a Measuring Tape & a Scale to complete the Self Fit-Test 
                    

  * Info Required to Receive Body Age Results        º Optional to Receive Additional Test Data
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 * Name:   * Company

 * Gender  Male      Female

 * Birth Date:   / /
                         Month /       Day /        Year    (Must be 18 to receive Body Age test results)

 * Email: (your results will be sent here)

This is My First Body Age Test
This is a Re-Test Submission


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* Physical Activity Readiness Questionnaire - PAR-Q

For most people physical activity should not pose any problem or hazard. PAR-Q has been designed to identify
the small number of adults for whom physical activity might be inappropriate or those who should have medical
advice concerning the type of activity most suitable for them.

Common sense is your best guide in answering these few questions. Please read them carefully and check the
yes or no opposite the question if it applies to you.

YES  NO

1.        Has your doctor ever said you have heart trouble?

2.        Do you frequently have pains in your heart and chest?

3.        Do you often feel faint or have spells of severe dizziness?

4.         Has a doctor ever said your blood pressure was too high?

5.        Has your doctor ever told you that you have a bone or joint problem such as
               arthritis that has been aggravated by exercise, or might be made worse with exercise?

6.        Is there a good physical reason not mentioned here why you should not follow an
               activity program even if you wanted to?

7.        Are you over age 65 and not accustomed to vigorous exercise?

If you answered YES to one or more PAR-Q questions:
Consult with your personal physician by telephone or in person before increasing your
physical activity and/or taking the Strength - Push Up Test in this assessment.

If you answered NO to all questions:
If you answered PAR-Q accurately with a "No" to all 7 questions you have reasonable
assurance of your present suitability for engaging in exercise or an exercise test.


* INFORMED CONSENT AND REQUEST TO PARTICIPATE IN
  HEALTH-RELATED EVALUATION & PROGRAMMING
I hereby acknowledge that I have reviewed my Physical Activity Readiness Questionnaire (PAR-Q) above, and that if I have answered “Yes” to any questions that I have been advised to consult with my physician before engaging in fitness testing or exercise. I hereby request the opportunity to participate in a health and fitness evaluation consisting of physical exercise. I hereby acknowledge that my participation in this evaluation and disclosure of any health history is entirely voluntary on my part. Such participation is solely for my own knowledge and benefit. The personal results will be kept confidential and not shared with any others. Your permission to perform this evaluation is voluntary, you are free to deny consent or stop the evaluation at any point, if you so desire. I understand that there is an inherent risk of injury and or death from exercise, and I assume all responsibility for such risk.

  YES, I have read and Agree to the Informed Consent release above.

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  Biometrics
 * Height in Inches: inches       * Weight: lbs.

  º Blood Pressure: Systolic / Diastolic     (You can check your BP at your local pharmacy)

º Resting Heart Rate: BPM (Take your pulse for 1 minute in a State of Rest and insert total Beats Per Minute BPM)
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  * Non Exercise - VO2 Max Estimate

Select the ONE CHOICE BELOW- that best describes your current exercise program:
 
 I don’t participate in regularly programmed recreation, sports, or heavy physical activity 
           I avoid walking or exertion (e.g., I use an elevator instead of stairs, I drive when possible instead of walking)               
           I walk for pleasure, routinely use stairs, occasionally exercise hard enough to perspire or breathe heavily.               
  I participate regularly in recreation or work requiring modest physical activity (such as golf, horseback riding, calisthenics,
gymnastics, table tennis, bowling, weight lifting, yard work).
           This activity takes 10 – 60 mins per week 
           This activity takes more than 60 mins per week 
I participate regularly in heavy physical exercise (such as jogging, swimming, cycling, rowing, jump rope, or engaging in
 aerobic activity such as playing tennis, basketball, or racquetball)                                          
           I run less than 1 mile per week or spend less than 30 minutes per week in comparable activity.
           I run 1 – 5 miles per week or spend 30 to 60 minutes per week in comparable activity.
           I run 6 – 10 miles per week or spend 1 to 3 hours per week in comparable activity.   
           I run 10 miles per week or spend over 3 hours per week in comparable activity.

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 * Body Composition: Using a 3 Site Circumference Test
  

 Use a Measuring Tape & Record in INCHES

 


Male - Circumference Measure Sites:                          Female - Circumference Measure Sites:
Male-Buttocks: (##.##) inches                                            Female-Abdomen: (##.##) inches
Measure at the maximum posterior (rear) protrusion of the buttocks.                        Measure at the greatest anterior (front) protrusion of the abdomen, usually at the navel.   
Male-Abdomen: (##.##) inches                                           Female-Right Thigh: (##.##) inches   
Measure at the greatest anterior (front) protrusion of the abdomen,                         Measure just below the gluteal (butt) fold.
usually at the navel.   
Male-Right Forearm: (##.##) inches                                 Female-Right Calf: (##.##) inches
Measure at the maximum circumference of the midforearm w/                                Measure at the maximum circumference of the calf w/ weight evenly distributed.
elbow extended.
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 * Flexibility - Sit & Reach Test
 Sit on the Floor with Legs Extended knees locked

 Bend Forward and Reach your Finger Tips towards Your Toes - Document Your Results Below

 Your Sit & Reach - Choose the choice below that Best describes Your Results:
  Finger Tips Reach to Mid Shin or less.
  Finger Tips Reach to your Ankle Joint
  Finger Tips Reach to your Toes
  Finger Tips Reach to 3 inches Past your Toes
  Finger Tips Reach to 6 inches Past your Toes

If you have access to a Sit & Reach Box Place "Scale 2 Cooper Institute score" Here (##.##) inches   

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 * Strength - You may choose the Push Up Test, Sit Up Test or Both Tests.

 * Strength - Push Up Test
  Number of Push Ups Completed within 60 Sec Time

 
 Male - Number of Regulation Push Ups: (within 60 Seconds)


 Female - Number of Modified Push Ups:  (within 60 Seconds)
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  * Strength - Sit Up Test
  Number of Full Sit Ups completed within 60 Sec Time

 * Insert # of Full Sit Ups: (within 60 Seconds)

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INPUT DATA BELOW TO RECEIVE PERSONAL TRAINING PROGRAM DESIGN
 

 My Personal Fitness Program Goal(s): Check Appropriate Box(es)

         Weight Loss        Increase Strength         Increase Flexibility

        Increase Cardio Conditioning        Stress Reduction

       I Need a Plan FOCUSED on Decreasing Low Back Pain

Your Occupational Activity Level

         Light - Sitting mostly
         Moderate - Walking and some lifting
         Heavy - Walking with heavy lifting
         Very Heavy - Very heavy physical work

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     Your Body Composition Goal (Percent Body Fat Goal)

      My Goal Body Weight is LBS

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    Meal Planner

    Diet Restrictions

    General Diet No Restriction Weight Loss Hypertension Heart Disease Cancer Prevention Diabeties High Protein Vegetarian

    Meal Preferences

      Breakfast - Preferences
       
        Cereal (Cold & Hot)
        Eggs, Omelets
        Pancakes, Muffins, Breakfast Rolls
        Yogurt
        Fruit Juice

        Lunch- Preferences

        Meat, Poultry & Seafood
        Pasta, Pizza, Rice & Beans
        Sandwiches, Hamburgers
        Soups & Salads
        Dessert

        Dinner - Preferences
       
        Meat, Poultry & Seafood
        Pasta, Pizza, Rice & Beans
        Sandwiches, Hamburgers
        Soups & Salads
        Vegetables 
        Dessert

        Snack - Preferences

        Chips, Snack Foods
        Nuts, Seeds
        Vegetables
        Fruits
        Sweets, Candy
 

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 Choose Any Activities You Enjoy Below:
       
        Aerobics / Normal
        Aerobics / Vigorous
        Aerobics / Step
        Basketball / Moderate
        Basketball / Competitive
        Bicycle / Leisure
        Bicycle / Light
        Bicycle / Moderate
          Bicycle / Racing
        Dance / Moderate
        Dance / Vigorous
        Field Hockey
        Football
        Golf / Walking
        Gymnastics
        Handball
        Hiking
        Judo / Karate
        Racquet Ball
        Rowing       
        Running / Leisure
        Running / Light
        Running / Moderate
        Running /Vigorous
        Running Very Vigorously
        Running / Racing
        Skating / Rollerblading
        Skiing Downhill
        Skiing Cross Country
        Squash
        Soccer
        Swimming / Back Stroke
        Swimming / Breast Stroke
        Swimming / Crawl
        Swimming / Side
        Tennis / Moderate
        Tennis / Competitive
        Volleyball
        Walking
        Wrestling
        Softball
        Circuit Training w/ Weights
        Elliptical Cross Trainer
        Golf / Carrying Clubs
        Horseback Riding
        Ice Skating
        In-line Skating
        Jump Rope
        Kayaking
        Rock Climbing
        Rowing Machine
        Skate Boarding
        Ski Machine
        Snow Shoeing
        Surfing
        Stair Climber
        Ultimate Frisbee
        Water Aerobics
        Water Skiing
        Weeding a Garden
        Weight Training
        Yoga