Existing member reassessment

You will need the following equipment to perform the self assessments:

A chair
A broomstick
A clock with a seconds hand (preferably a wall clock)
A doorway

Please go through the form and fill in the answers.

Back rotation test

Sit and reach test

Back scratch test

Wall pushups

Single leg balance test

Sit to stands

Name*
First Last
Email*
Date of self assessment*
MM slash DD slash YYYY
Date of Birth*

Day
Month
Year
How can we help?
Have you had any recent medical changes including changes to your medications or any new aches or pains since your last reassessment?
Are there any exercises in your current exercise program that you feel you are greatly benefiting from that you would like to keep in your next program?
Are there any movements, exercises or positions that cause you discomfort?
Are there any key area you would like us to focus on for your next program?
Are there any positive health changes that you have noticed since beginning your last program?
Please select any equipment that you have access to at home
- Hand weights
- Theraband or elastic tubing
- Exercise bike
- Treadmill
- Other
Other equipment
What is your medical history?

Please write N/A instead of leaving an answer blank.
How easily do you move?
Back scratch test right arm above*
If other please give details
Back scratch test left arm above*
If other please give details
Number of complete sit to stands in 30 seconds*
Please write down what you feel limited this test result (eg pain, out of breath, legs tired)
Sit and reach result*
If other please give details
Single leg balance time in seconds right leg*
Single leg balance time in seconds left leg*
Please write down what you feel limited this test result (eg pain, difficulty balancing, legs tired)
Number of complete wall pushups in 30 seconds*
Please write down what you feel limited this test result (eg pain, out of breath, arms tired)
Back rotation towards right*
Back rotation towards left*
If other please give details
Please write any additional comments that you have about any of the test results
Do you wish for one of our staff to contact you to arrange a Telehealth virtual consultation prior to designing your exercise program?
If you answered yes above, please provide us with your best contact number so that we can call you and organise this
Our responsibility to you is to use all of the available information as well as our clinical knowledge to ensure that you are only asked to perform what we consider to be both safe and appropriate to your condition. We will guide and supervise you to the best of our abilities to keep you as safe as possible. It is your responsibility to inform us of all relevant medical information that may affect your ability to exercise or participate in the assessment activities. It is also your responsibility to inform us of any concerns, pains or other symptoms that you may experience while you are under our care. Please select the appropriate response below.*
- To the best of my knowledge I have provided accurate information and consent to the terms and conditions described above.
- I would prefer to speak to a staff member to clarify my understanding of the responsibilities as set out above

Existing member reassessment

Back rotation test

Sit and reach test

Back scratch test

Wall pushups

Single leg balance test

Sit to stands

How can we help?

What is your medical history?

How easily do you move?

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