1-2-3-4 Assessment

Client Name _____________________ Date _________________

Phone Number _____________________ Age __________

DOB _____________ Height __________ Current Weight _________

Emergency Contact _________________________ Relation ________

1) Single Leg Stand Assessment:

❏ Can stand on one leg for 20 seconds
❏ Can stand on one leg for 10 to 20 seconds
❏ Can stand on one leg for 10 seconds
❏ Cannot stand on one leg for 10 seconds

2) Physical Assessments:

Weight
❏ Client’s weight is under 300 pounds
- Measured Weight _____________
❏ Client’s weight is 300 pounds or over
Medically cleared to exercise?
❏ Yes
❏ No (refer to medical professional for clearance)

Height/Waist
Height (inches) ________ Waist (inches) ________
❏ Height & Waist are a 2:1 ratio
❏ Height & Waist are not a 2:1 ratio
3) Lifestyle Questions:

1. How many pillows does it take for you to sleep comfortably at night?
(other questions about nagging injuries for mobility concerns)
____________________________________________________________
____________________________________________________
2. In your diet, do you try to include lots of colorful vegetables in meals?
(conversation about nutrition because all clients “eat healthy”)
____________________________________________________________
____________________________________________________
3. Throughout your day, do you try to exercise at least 30 mins per day?
(conversation about daily habits and what motivates the client)
____________________________________________________________
____________________________________________________________
________________________________________________

4) Movement Analysis:
2 Minute Plank Hold (Strength Test)
❏ Held for 2 minutes
❏ Held for _________
Get Back Ups (Mobility Test)
❏ Completed hands free series
❏ Could not complete hands free series
Standing Long Jump (Body Composition/Awareness)
❏ Distance (inches) ___________
Farmers Walk at Bodyweight (Cardiovascular Health)
❏ Duration (time) ___________