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PHRE 3043 – Data Submission
Data Collection - PHRE 3043 - Old
Client Info
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Sex
*
Male
Female
Body Weight (kg)
*
kg
Height (cm)
*
cm
Age
*
Activity Readiness Screening
Get Active Questionnaire Complete
Yes
Resting HR (bpm)
bpm
Systolic BP
mmHg
Diastolic BP
mmHg
PIN Assessment Data
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Push Up - Raw Score (#)
Push Up - PIN Score
Sit and Reach - Raw Score (cm)
Sit and Reach - PIN Score
Back Extension - Raw Time
Back Extension - PIN Score
1.5 Mile Run - Raw Time
1.5 Mile Run - PIN Score
Total
Did you meet the PIN Fitness Award standard?
No
Yes
1.5 Mile Data
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RPE (1-10)
Average HR (bpm)
HR at the end of the run (bpm)
Time (min)
Convert your seconds to a decimal.
VO2 max 1
ml/kg/min
VO2 max 2
ml/kg/min
PREP Circuit Data
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Time for Circuit (sec)
sec
Did you meet the 157s circuit standard (wearing 18 lbs)
Yes
No
Peak RPE for Circuit (1-10)
Peak HR for Circuit (bpm)
bpm
Average HR for Circuit (bpm)
bpm
20M Shuttle Run Data
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20M shuttle run stage:
Did you meet the PREP standard
Yes
No
Peak RPE for 20M shuttle run (1-10)
Peak HR for 20M shuttle run (bpm)
bpm
Average HR for 20M shuttle run (bpm)
bpm
PREP Assessor
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Were you a good assessor for the PREP
I am pretty good
I need some practice
Movement Screening
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Overhead Squat Score
Dowel Hinge Score
Scapular Wall Slide
Forearm Plank Hold
Excellent
Good
Needs Improvement
Poor
FMS Scores
Deep Squat Final Score
Hurdle Step Raw Score (Right)
Hurdle Step Raw Score (Left)
Hurdle Step Final Score
Inline Lunge Raw Score (Right)
Inline Lunge Raw Score (Left)
Inline Lunge Final Score
Shoulder Mobility Raw Score (Right)
Shoulder Mobility Raw Score (Left)
Shoulder clearing test (Right)
+
-
Shoulder clearing test (Left)
+
-
Shoulder Mobility Final Score
Active Straight Leg Lift Raw Score (Right)
Active Straight Leg Lift Raw Score (Left)
Active Straight Leg Lift Final Score
Trunk Stability Pushup Raw Score
Extension clearing test
+
-
Trunk Stability Pushup Final Score
Rotary Stability Raw Score (Right)
Rotary Stability Raw Score (Left)
Flexion clearning test
+
-
Rotary Stability Final Score
FMS Total Score & Weakest Link
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FMS Total Score (0-21)
Your 'Weakest Link'
Active Straight Leg Raise
Shoulder Mobility
Rotary Stability
Trunk Stability Pushup
Inline Lunge
Hurdle Step
Deep Squat
No weak link
Modern Burpee
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Number of Burpees (with proper form)
RPE (1-10)
HIIT prescription
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Training modality
Treadmill
Bike
Rowing machine
Prescription time for work (seconds)
s
Prescription time for rest (seconds)
s
Prescription intensity for work (% HRR)
%
Prescription for intensity for work (bpm)
bpm
HIIT Actual (what you did in training)
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1 - time (work; seconds)
s
1 - HR (work; bpm)
bpm
1 - RPE (work; 1-10)
1 - time (rest; seconds)
s
1 - HR (rest; bpm)
bpm
2 - time (work; seconds)
s
2 - HR (work; bpm)
bpm
2 - RPE (work; 1-10)
2 - time (rest; seconds)
s
2 - HR (rest; bpm)
bpm
3 - time (work; seconds)
s
3 - HR (work; bpm)
bpm
3 - RPE (work; 1-10)
3 - time (rest; seconds)
s
3 - HR (rest; bpm)
bpm
4 - time (work; seconds)
s
4 - HR (work; bpm)
bpm
4 - RPE (work; 1-10)
4 - time (rest; seconds)
s
4 - HR (rest; bpm)
bpm
5 - time (work; seconds)
s
5 - HR (work; bpm)
bpm
5 - RPE (work; 1-10)
5 - time (rest; seconds)
s
5 - HR (rest; bpm)
bpm
6 - time (work; seconds)
s
6 - HR (work; bpm)
bpm
6 - RPE (work; 1-10)
6 - time (rest; seconds)
s
6 - HR (rest; bpm)
bpm
7 - time (work; seconds)
s
7 - HR (work; bpm)
bpm
7 - RPE (work; 1-10)
7 - time (rest; seconds)
s
7 - HR (rest; bpm)
bpm
8 - time (work; seconds)
s
8 - HR (work; bpm)
bpm
8 - RPE (work; 1-10)
8 - time (rest; seconds)
s
8 - HR (rest; bpm)
bpm
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