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