Functional Fitness Assessment Plan
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Quantum Analyzer with David Lee.
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8-1168 Belanger Ave,
Ottawa, On, K1H 8A2
613.612.4372
info@vitalhealthlife.com
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In Person Nutrition Program
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Personal Information
Name
Email
Phone Number
Trainer
Select Trainer
Askar Shomayev
David Lee
Luz Campos ( Lucky Campos)
Richard Ouellette
Follow Update
Social Media
Select
Yes
No
What do you do? What kind of relationships exist in your Life? (i.e. husband, father, mother, etc.)
Current Membership
Your Goals And Objectives
Why?
Way To Success
Life Style
Current Physical Activities
Past Physical Activities
Past Diet Programs
Supplements
Current Medications
Last Antibiotic Taken
Past Surgeries (Birth - Present)
Bad Habits And Unhealthy Signs
Smoking
Select
No
Minimal
Moderate
High
Skip Meals
Select
No
Periodic
Sometimes
Most of the time
Fast Food
Select
Never
Periodic
Sometimes
Most of the time
Microwave
Select
Never
Sometimes
Most of the time
Constipation
Select
Never
Sometimes
Most of the time
Loose Stools
Select
Never
Sometimes
Most of the time
Sleep Disturbances, Restlessness
Select
Never
Sometimes
Most of the time
Dream
Select
Never
Sometimes
Most of the time
Sleep Hours
Select
less than 6
7-8 hours
More than 8
How Much Per Day
Meat
Select
No Meat
4 Ounces
8 Ounces
16 Ounces
Dairy
Select
>1 Serving
1 Serving
Alcohol
Select
None
>1
1
2+
Coffee
Select
None
>1
1
2+
White Foods (Sugar, Flour, Rice)
Select
None
Periodic
1 Serving
2+ Serving
Store bought Juice or Pop
Select
>1
1
2+
Do you eat more cooked vegetables than raw?
Select
None
Periodic
Sometimes
Most of the time
Do you consume organic meats and/or produce?
Select
None
Periodic
Sometimes
Most of the time
Symptom Frequency
Indigestion, Bloating, Discomfort :
Select
None
Periodic
Sometimes
Most of the time
Muscle Aches:
Select
None
Periodic
Sometimes
Most of the time
Fatigue, Lethargy:
Select
None
Periodic
Sometimes
Most of the time
Cravings & High Appetite:
Select
None
Periodic
Sometimes
Most of the time
Happiness Level:
Select
Low
Medium
Higher
Isolation, Passiveness:
Rating
1
2
3
4
5
6
7
8
9
10
Anxiety/Stress Level:
Rating
1
2
3
4
5
6
7
8
9
10
Irritability, Anger:
Rating
1
2
3
4
5
6
7
8
9
10
Headaches:
Select
None
Periodic
Sometimes
Most of the time
Memory Level:
Select
Low
Medium
Higher
Body Assesment
Past/Current Injuries and Pains:
Static Posture Assesment
Lateral
Posterior
Anterior
Locked Knees
Select
Yes
No
General Sleeping Position
Hand Dominance
Select
Left
Right
Age
Height
Current Weight
Wrist Pro.
Sup.
Flex.
Ext.
Neck Flexion
Length Tension Assesment Results
Forward Bend (Check for scoliosis)
Back Bend
Lateral Flexion
Rotation of Spine
Thomas Test R
Thomas Test L
Hamstrings Tightness
Calves
Quadriceps
Adductors
Abductors
Plantarflexion
Dorsiflexion
Ankle Inversion
Ankle Eversion
LatissimusDorsi
Pectoralis Major
Pectoralis Minor
Shoulder Extension
Internal Rotation
External Rotation
Functional Movement Results
Get Up Right
Get Up Left
Sit Down Right
Sit Down Left
Single Leg Stance Right Foot
Single Leg Stance Left Foot
Wall Squat Hands Touching Wall
Weight-less Squat
Plank Test Touch Elbow
Protract/Retract
Push Up Test
Pull Test (chin-up, cables, bands)
Oblique R / L (on table or mat)
Medial Glute R / L
Upper Ab (lying on table curl up)
Lower Ab (leg let down)
Buttock Lift (on table)
Notes:
Back
Next
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