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About Us
Contact Us
Disclaimer
Privacy Policy
Contemplate
Pledge
Assess
Plan
Implement
Body Composition Analysis
*
Indicates required field
Medical-Fitness Facility:
*
Date:
*
MM/DD/YY
Client's Name:
*
First
Last
Phone #:
*
Gender:
*
Male
Female
Age:
*
Height:
*
F' II"
Weight:
*
Pounds
BMI:
*
Waist Circumference:
*
Measured to the nearest half-inch at the umbilicus (belly-button). Required only if client's BMI Category is NOT obese.
Percent Body Fat:
*
Optional: If measured accurately using BIA.
Body Composition Category:
*
Underweight
Healthy Weight
Overweight
Obese 1
Obese 2
Obese 3
AFTER potential adjustment by client's WC and/or %BF.
Weight-Related Health Risk Category:
*
Possible Health Risks
Low Health Risks
Mild Health Risks
Moderate Health Risks
Severe Health Risks
Extreme Health Risks
Optimal Wt Range:
*
Optimal Weight Range: Refer to BMI Chart Healthy Weight Range for Height.
Optimal %BF Range
*
Male = 10-20% Female = 15-25%
Sports Med-Tech Assistant:
*
Excess Fat-Weight:
*
Goal Date:
*
Impression:
*
Recommendations:
*
Sports Medicine Consultation
Fitness Analysis
Blood Chemistry Analysis
Therapeutic Fitness Training
Nutrition Analysis
Lifestyle Medicine Consultation
Medical Integration
Other
If "Other" above, specify below:
*
Follow-Up:
*
# of Weeks or Months
Sports Medicine Technician:
*
Submit