Name _________________________________________Section ______________ Date _____________

Student Pre-course Health Assessment

Student ID#____________________ Age ____________
Date of last medical checkup__________________
Please answer all of the questions completely and honestly. This document is confidential between the student,
instructor, and administration. This form is used to help you stay safe in courses that have physical activities. If at
any time you do not feel well or experience an injury, please tell your instructor immediate. While your
participation in this course may enhance your health and well being, you are advised that participation in some
activities may be extremely vigorous and have potential risks. If you have any questions about the course or
activities please talk to your Instructor. It is highly recommended that you see your personal physician before you
begin this class. The presence of some of the following conditions may affect your performance. Please check any
conditions listed that pertains to you.
____ Cardiac/ respiratory problems
____ Chest pain or discomfort
____ Severe allergic reactions
____ High blood pressure (140/90 or above)
____ Pregnancy
____ Severe headaches
____ Family history of heart disease
____ Asthma (any)
____ Epilepsy (seizures/grand mal, 3+min)
____ Diabetes
____ Fainting spells/sudden unconsciousness
____ Other life threatening conditions (please list) ___________________________________________
____ knee injuries
____ Back injuries
____ Scoliosis
____ Shoulder injuries
____ Neck/spinal injuries
____ Foot injuries
____ Smoker
____ Other, please list below
Please list any other medical conditions or information you think should be brought to the
Attention of your instructor. _____________________________________________________________
Please list all medications that you like take regularly. _________________________________________

If during this class/course your physical health changes in regards to any of the listed or other conditions, please
notify your instructor immediately.

By signing this form I understand my responsibility toward staying safe in this course and informing my instructor
that I am not withholding any information regarding my health status.

(Please sign, date, and return this form to your instructor.)

Student Signature__________________________ Date_______________________

Physical education –is an integral part of the educational program designed to promote the optimum
development of the individual physically, socially, and mentally through total body movement in the performance
of property selected activities.

Aim of Physical Education – is to enable all students to enhance their quality of life through active living.

Objectives of Physical Education – Physical Development, social development, emotional development and mental
development

Importance of Physical Education - Quality physical education programs are needed to increase the physical
competence, health related fitness, self-responsibility and enjoyment of physical activity for all students so that
they can be physically active for a lifelong.

What should physical educated students know and be able to do?

- Learned skills necessary tom perform a variety of physical activities
- Must be physical fit
- Participates regularly in physical activities
- Knows the implication of and the benefits from involvement in physical activities
- Values physical activity and its contribution to a healthful lifestyle.
Fitness – is the ability to perform daily tasks vigorously and alertly, with energy left over for enjoying leisure-time
activities and meeting emergency demands. It is the ability to endure, to bear up, to withstand stress, to carry on
circumstances where an unfit person could not continue, and is a major basis for good health and well-being.

Components of Physical Fitness

Health-Related Components: Those factors that are related to how well system of your body work

1. Cardiovascular Fitness: The ability of the circulatory system (heart and blood vessels) to supply oxygen to
working muscles during exercise.
2. Body Composition: The relative percentage of body fat compared to lean body mass (muscle, bone, water,
etc)
3. Flexibility: The range of movement possible at various joints.
4. Muscular Strength: The amount of force that can be produced by a single contraction of a muscle.
5. Muscular Endurance: The ability of a muscle group to continue muscle movement over a length of time.

Skilled-Related Components: those aspects of fitness which form the basis for successful sports participation.

1. Speed: The ability to move quickly from one point to another

2. Agility: The ability of the body to change direction quickly
3. Balance: The Ability to maintain an upright posture while still or moving
4. Coordination: Integration with hand and/or foot movements with the input of the senses
5. Reaction Time: Amount of time it takes to get moving
6. Power: The Ability to do strength work at an explosive pace.
Check Your Heart Rate

Name _________________________________________Section _______________________ Date _____________________

Gender __________ Age _______

Using a stop watch or a watch with secondhand, practice counting your heart rate (pulse) at the locations and various lengths of
time listed. Be sure to use your fingertips, not your thumb to accurate count the heartbeats. Practice finding the pulse at the
three locations quickly, this is important when trying to count your after exercising.

1. One-Minute Heart rate Count. Count each heartbeat for 1 minute.

Over the heart pulse = ________________beats/minute

Carotid pulse (neck) = ________________beats/minute
Wrist/radial pulse (thumb side) = ________________ beats/minute

How did the count at these three locations compare?

Which location did you find most convenient?

Why?

2. Thirty-Second Heart rate Count. Count each heartbeat for 30 seconds. Multiply the count by two to calculate per
minute (bpm).

Over the heart pulse _____________ = ____________ beats/minute

Carotid pulse (neck) _____________ = ____________ beats/minute
Wrist/radial pulse (thumb side) _____________ = ____________ beat/minute

3. Fifteen-Second Heart Rate Count. Count each heart for 15 seconds, Multiply the count by four calculate beats/minute
(bpm).

Over the heart pulse ____________ = _____________ beats/minute

Carotid pulse (neck) ____________ = _____________ beats/minute
Wrist/radial pulse (thumb side) ____________ = _____________ beats/minute

4. Ten-Second Heart Rate Count. Count each heartbeat for 10 seconds. Multiply then count by six to calculate
beats/minute (bpm).

Over the heart pulse ____________ = _____________ beats/minute

Carotid pulse (neck) ____________ = _____________ beats/minute
 Wrist/radial pulse (thumb side) ____________ = _____________ beats/minute

5. Six-Second Heart Rate Count. Count each heartbeat for 6 seconds. Add zero to the count to calculate beats/minute
(bpm).

Over the heart pulse ____________ = _____________ beats/minute

Carotid pulse (neck) ____________ = _____________ beats/minute
Wrist/radial pulse (thumb side) ____________ = _____________ beats/minute

6. Which time length do you prefer?

___________ 1-minute _____________ 10-second

___________ 30-second _____________ 6-second
___________ 15-second

Why?

How do they compare?

3-MINUTE STEP TEST

Miller, David K. (2006). Measurement by the Physical Educator (Fifth Edition) McGraw-hill

Test Objective. To measure Cardio Respiratory fitness with a sub-maximal tests.

Equipment. A bench 12 inches high, a stopwatch, and a metronome.

Administration and Directions. All test performance should have a partner to count the carotid pulse (allow time to practice
counting a partner’s carotid pulse). On the signal to begin. the test performer steps up with one foot, then the other; step down
with the first foot, then the other foot, the knees must straight with the step on the bench. The complete step represents 4
counts (up, up, down, down). The step is done at a cadence of 96 counts/minute or 24 complete step executions/minute (one
4-count step every 2.5 seconds). At the conclusions of 3 minute, the test performer quickly sits down, and the partner counts
the pulse for 1 minute.

Scoring. The score is the total 1-minute post-test pulse count.

3-Minute Step test

Rating Males Females
Excellent >79 <85
Good 79-89 85-98
Above Average 90-99 99-108
Average 100-105 109-117
Below Average 106-116 118-126
Poor 117-128 127-140
Very Poor >28 >140
Waist To Hip Ratio
Hoeger, Werner WK. & Hoeger , Sharon A. (2006). Principles and Labs for Fitness and Wellness .(Eight Edition.) CA. Thomson
Wadsworth.

To Determine the Waist to hip ratio, perform the following steps.

1. Measure around the waist where it is the smallest; stand relaxed and do not pull in stomach
2. Measure the hips where they are the largest.
3. Divide the waist measurement by the hips measurement to obtain waist to hip ratio.
Note: Measure in inches

Recommended Standards
Waist Circumference
Men Women Disease Risk
<35.5 <32.5 Low
35.5-40.0 32.5-35.0 Moderate
>40.0 >35.0 High

Waist to Hip Ratio

Men Women Disease Risk
0.95 0.80 Very Low
0.96-0.99 0.81-0.84 Low
1.00 0.85 High

BODY MASS INDEX (BMI)

Formula for computing =Weight in Kilograms ÷ Height in meter²
Note: 1 kg = 2.2 pounds, and 1 m = 39.37 inches

Classification BMI
Obese (high risk) Over 30
Marginal 25 – 30
Good fitness zone 17 – 24.9
Low Less than 17

Sit and Reach Wall Test

The Sit and Reach Walla Test is a self-check for flexibility and can quickly be performed by a large number of people. All you
need is a wall.
Goal: To measure flexibility of the hamstrings.
Directions:
1. Warm-up by Walking and static stretching
2. Remove shoes, sit facing a wall, and keep your feet flat the wall and your knee straight
3. Reach forward as far as possible to touch your fingertips, knuckles, or palms to the wall and hold the position for 3
seconds
4. Check your flexibility evaluation.
 Sit and Reach Wall Test Scores
Result Rating
Cannot touch wall low
Fingertips touch wall Average
Knuckles touch wall Good
Palms touch wall Superior

Trunk Extension
Starting Position: Prone lying position with hands in line the chest
Instructions: From prone lying position, push upper body upward keeping hips in contacts with the floor. Elbows should be
straight.
Result Rating
No Movement from the floor Very good
2 inches or below Average
More than 2 inches from the floor Tight

Shoulder Adductors
Starting Position: Supine Lying Position with arms at the sides of the body
Instructions: From supine lying position, bring the arms overhead, back of the hand should be in contact with the floor, elbow
straight, arms should be close to the ears – arm (bicep area) should lay flat on the floor.

Result Rating
No Movement from the floor Very good
2 inches or below Average
More than 2 inches from the floor Tight

Multirotational Components (Shoulders)

Starting Position: Standing Position
Instructions: Bring right arm overhead then bend the below reaching the left hand with the right hand. Bend ;left elbow
reaching the right hand with the left hand, reach hands together at the back.
Note: Measure both right and Left (Right arm up is right, left arm is left)
Result Rating
More than 2 inches overlap Very good
2 inches overlap to 2 inches apart Average
More than 2 inches apart Tight

Right Angle Push – ups

 Purpose – To measure the endurance of the arms and upper body muscles.
 Equipment – None
 Procedure – a. The performer lie face down on the floor with the hands on the floor and thumbs in line the shoulder:
b. The legs should be slight apart, knees straight
c. Keeping the legs and back straight; the performer pushes off and assumes the stating position
d. Performer bends the elbows and lowers the body until the arms are at a right angle (90 degrees)
e. Performer repeats the movement for a maximum of 50 for boys and 30 for girls
f. Stop the performer when he/she commits two (2) form breaks, such as failure to go down at 90 degree
angles, extend the elbows fully, unable to keep the legs and back straight, or maintain the cadence of one
second count in going down and one second in going up.
 Scoring – Record the number of push-ups completed
 Right Angle Push-Ups Test Norms

Rating Female Male

Superior >30 >50
Good 25-29 40-49
Average 20-24 30-39
Fair 15-19 20-29
Low <10-14 <20

1 MINUTE ABDOMINAL CURL

Robbins, Gwen, Powers, Debbi, & Burgess, Sharon. (2008). A Wellness Way of Life. (Seventh Edition). New York: McGraw Hill.

Goal: To complete as many abdominal curls as possible in 1 minute.

Directions:
1. Tape a 3-inch-wide strip on the floor and lie on your back on the floor with your fingertips at the edge of the strip.
Bend your knees, and bring your heels as close as possible to your buttocks.
2. Curl forward until your fingertips have moved forward across the 3-inch strip and then curl back until your shoulder
blades touch the floor. Your shoulders should lift from the floor with each curl, but the lower back should stay on the
ground, If you are working with a partner who is counting your curls, your partner should not hold your feet down,
nor should your feet lift off the ground – if they do, you are curling too high.
3. Complete as many curls as possible in 1 minute; then check results.

1-Minute Abdominal Curls Test Norms

Rating Female Male
Superior >88 >93
Good 75-88 79-93
Average 60-74 64-78
Fair 45-59 50-63
Low <45 <50

SQUAT TEST
http://www.topendsports.com/testing/test/home-squat.htm
Goal: To perform as many squats until exhaustion
Directions: Stand in front of a chair or bench with your feet at shoulder’s width apart, facing away from it. Place your hands on
your hips. Squat down and lightly touch the chair before standing back up. A good sized chair is one that makes your knees right
angles when you are sitting. Keep doing this until you’re fatigued.

Squat Test Norms

Rating Female Male
Excellent >43 >49
Good 37-43 44-49
Above Average 33-36 39-43
Average 29-32 35-38
Below Average 25-28 31-34
Poor 18-24 25-30
Very Poor <18 <25
Name: Section:

Age:

Pre-Test Physical Fitness Test

Date:

Health-Related Fitness Physical Fitness Tests Score/Result Rating

1. Cardio-  3-minute step test

Respiratory
Fitness
2. Body  Waist-to-hip-ratio Recommended Standards Disease Risk:
Composition Waist Circumference:
 Waist-to-hip ratio Disease Risk:

 BMI

3. Flexibility  Sit and reach wall test

 Shoulder adductors
 Trunk extensions
 Multi-rational Right Arm: Right Arm:
shoulders Left Arm: Left Arm:
4. Muscular  Right angle push up
Endurance  Abdominal curl-up
 Squat Test

Waist Circumference: Hips Circumference:

Recommended Standard

Disease Risk:

Weight: lbs kg

Height: feet & Inches meters meters2

Name: Section:

Age:

Pre-Test Physical Fitness Test

Date:

Health-Related Fitness Physical Fitness Tests Score/Result Rating

5. Cardio-  3-minute step test

Respiratory
Fitness
6. Body  Waist-to-hip-ratio Recommended Standards Disease Risk:
Composition Waist Circumference:
 Waist-to-hip ratio Disease Risk:

 BMI

7. Flexibility  Sit and reach wall test

 Shoulder adductors
 Trunk extensions
 Multi-rational Right Arm: Right Arm:
shoulders Left Arm: Left Arm:
8. Muscular  Right angle push up
Endurance  Abdominal curl-up
 Squat Test

Waist Circumference: Hips Circumference:

Recommended Standard

Disease Risk:

Weight: lbs kg

Height: feet & Inches meters meters2