NHE Fitness Management Profile Form (FMPF-N) Sample

PFMS Instructions: Design a one (1) day fitness program (Muscular Development, Cardio, Flexibility).

Profile Name:
Carter, Steven   
     
Profile Date:
06/19/2013   
      
Weight:
207 lbs    
      
Age:
32   

 

Resting BP:
132/85   
       
Resting HR:
70          

Height:
5 Ft 10 in     
     
Physical Limitations:
Restricted ROM in RT deltoid

Bioelectrical Impedance ReadingBF%:17 

 

Sex: M

 

Body Measurements:
Chest: 46 in    Neck: 17 in
Waist: 41 in    Hips: 40 in    
Ankle: 10/10 in (Right/Left)    
Upper Arm: 15/ 15.5 in (Right/Left)      
Thigh: 24.25/24in (Right/Left)
Wrist: 8/8 in (Right/Left)
Calf: 16/16.25 in (Right/Left) 

 

Fitness Goal(s):
1) Lose 15-20 pounds.
2) Increase biceps and triceps strength and size.
3) Strengthen core.
4) Improve cardiovascular endurance.



Fitness Access/Schedule:
Complete cardio/WT facility. 45-60 min, 3xWK. 

Anatomical Concerns:

[Not applicable on this sample form.]

 

[Red] Beginning Date: _______ End Date: _______

 

[Blue] Beginning Date: _______ End Date: _______

 

[Green] Beginning Date: _______ End Date: _______

 

Notes:

Fitness Assessment:

(In relation to member's profile)


1) Program Type Preference: Normal, not too advanced.
2) Cardiovascular: Poor
3) Weight Training Experience: High school football
4) Muscular Endurance: Average
5) Cardiovascular Machine Favorite: Treadmill
6) Muscular Strength: Average
7) Exercise Terminology: Average
8) Flexibility: Poor
9) Core Development: Poor

Health Questionnaire:

1) [No]   
2) [No]   
3) [Yes]   
4) [No]   
5) [No]   
6) [No]   
7) [No]   
8) [No]   
9) [No]   
10) [No]  
11) [No]  
12) [No]

 



1) Ischemia.
2) Smoke.
3) Drink [beer, six pack on weekends].
4) Edema.
5) Known heart murmur.
6) Intermittent claudication.
7) Palpitations or tachycardia.
8) Shortness of breath at rest or with mild exertion.
9) Dizziness or syncope at rest or with mild exertion.
10) Unusual fatigue or shortness of breath with usual activities.
11) Orthopnea/paroxysmal nocturnal dyspnea at rest or w/mild exertion.
12) Pain or discomfort (or anginal equivalent) in the chest, neck, jaw, arms.

Family History:

1) [No]   
2) [No]   
3) [Yes]   
4) [No]   
5) [No]   
6) [No]   
7) [No]   
8) [No]   
9) [No]   
10) [No] 

1) Heart attack or surgery prior to age 55.
2) Stroke prior to age 50.
3) Congenital heart disease or left ventricular hypertrophy.
4) Hypertension.
5) Leukemia or cancer prior to age 60.
6) High cholesterol.
7) Diabetes.
8) Asthma.
9) Osteoporosis.
10) Depression.

Medications:

1) [No]   Diuretics
2) [No]   Beta Blockers
3) [No]   Vasodilators
4) [No]   Alpha Blockers
5) [No]   Calcium Channel Blockers
6) [No]   NSAIDS
7) [No]   Cholesterol
8) [No]   Diabetes.Insulin
9) [No]    Birth Control
10) [No]   Other Drug___

ORC [Other Relevant Condition(s)]:
1) Post-traumatic Arthritis in right knee. (Doctored cleared)
2) Acute low back discomfort. (Doctored cleared)

Form FMPF 13-8320-0043                                                                                                                                                                                                                                                                 NHE-CATF 96033350112