fitness assessment form exhibit a

Fitness Assessment FormExhibit A

VI_FA_1013© 2014 The Vitality Group

Accrediting Organization Accreditation Type How to locate

American College of Sports Medicine Certified Personal Trainer http://forms.acsm.org/_frm/crt/online_locator.asp

American Council on Exercise Personal Trainer Advanced Health and Fitness Advanced Health and Fitness Specialist

http://www.acefitness.org

Aerobics and Fitness Association of America Personal Trainer http://www.afaa.com/

The Cooper Institute Personal Trainer Certification www.cooperinst.org

International Fitness Professionals Association Certified Personal Trainer http://www.ifpa-fitness.com/

National Academy of Sports Medicine Certified Personal Trainer http://www.nasm.org/

National Athletic Trainers’ Association Board of Certification Entry-Level Athletic Trainer Certification http://www.nata.org/

National Council on Strength and Fitness National Certified Personal Trainer http://www.ncsf.org/certverification.aspx

National Exercise and Sports Trainers Association Certified Personal Fitness Trainer www.nestacertified.com

National Exercise Trainers Association Certified Personal Trainer http://www.ndeita.com/

National Strength and Conditioning Association Certified Personal Trainer Certified Strength and Conditioning Specialist

http://www.nsca -lift.org/trainers/locator/

National Personal Trainer Institute Certified Personal Trainer http://nptifitness.com/

International Sports Science Association Certified Fitness Trainer http://www.issaonline.com/

In addition, any individual with a Master’s degree or higher in Exercise Physiology, Sports or Exercise Science, Physical Therapy, Occupational Therapy, or Medicine is qualified to administer a Fitness Assessment.

Fitness Assessment FormExhibit B

Expires 01/01/2014

First Name: Last Name:

Vitality ID: Date of Birth:


To earn Vitality Points, please send this completed form and the appropriate results form to:

Email: [email protected], fax: 877.224.7110, or mail to: The Vitality Group, 200 West Monroe, Suite 2100, Chicago, IL 60606

To qualify for Vitality Points, you must submit this form with the appropriate results form to Vitality using the

Member’s Signature: Date of Signature:

Facility Name: Address: Phone:

Weight:Height: Blood Pressure: Waist Circumference:

inches lbs mmHg inches

Fitness Professional’s Name: Title: Phone:

Fitness Assessment FormExhibit C

Expires 01/01/2014


To earn Vitality Points, please send this completed form and Exhibit B to:


All protocols must be executed according to the procedures below by a qualified fitness professional. Please submit this complet-ed form along with your Fitness Assessment Form, Exhibit B, to Vitality using the contact details below.

The YMCA Step test requires the individual to step for three minutes at a prescribed stepping cadence of 24 steps per minute. We suggest you orient the individual to the testing protocol prior to the test. Allow the individual to practice stepping to the prescribed cadence, and practice finding his or her pulse at the end of stepping so the person knows what to expect. Taking a minute to orient the individual to these procedures will enhance the reliability of the results.

Required materials: 1. 12.25 inch step 2. Stop watch 3. Metronome

Procedures: 1. Set the metronome to 96 beats per minute (24 steps per minute) 2. Allow the individual to practice stepping to the prescribed cadence. Each beat is a step “up” or “down.” a. Note that both feet must come up and down to complete a step, e.g., “up-up, down-down” 3. On the command, the individual should commence stepping as you start the watch.

4. After stepping for three minutes, instruct the individual to stop stepping and sit down on the step or in a chair while you find his or her radial pulse on the inside of the person’s wrist.

5. At 3:05, start counting the heart rate for 60 seconds so that you stop counting at 4:05. 6. Record the number of beats you counted for the 60 second period. a. NOTE: Do not use a heart rate monitor; please count the total beats in the one minute

following the test.

Important notes:

• The individual must remain still and seated during the measurement period following the test.• Any delay in measuring the heart rate after the test will produce an invalid result and require a retest on another

visit. Therefore, be sure to start measuring at 3:05.

Section A: Results (to be completed by fitness professional)Result (60 second heart rate count): Member Name: Vitality ID:

Fitness Professional’s Name: Date of Test:

Fitness Professional’s Signature: Date of Signature:

YMCA Step Test Protocol (Vitality Preferred)

Fitness Assessment FormExhibit D

Expires 01/01/2014




All protocols must be executed according to the procedures below and by a qualified fitness professional. Please submit this completed form along with your Fitness Assessment Form, Exhibit B, to Vitality using the contact details below.

The Bruce Treadmill Protocol is a progressive exercise test to exhaustion. As such, an individual must qualify as low risk as measured by standard risk stratification techniques. Given that the individual is classified as low risk he or she may complete the graded maximal exercise test.

• Each stage is three minutes in duration.• Start the test at 1.7 mph and 10% grade. Increase the speed

and grade thereafter according to the table on the left.• Follow standard maximal exercise testing guidelines regarding

volitional fatigue to determine whether or not the measurement was valid.

Required materials: 1. Treadmill capable of reaching at least 6.0 mph and at least

a 20% gradient 2. Stop watch

Optional materials: 1. Heart rate monitor for measurement of maximal heart rate

Procedures: 1. Start the stopwatch at the beginning of the first stage. 2. Change the speed and grade of the treadmill according to the table above. Each stage is three minutes in duration. 3. The individual should be encouraged to go for as long as possible to achieve a true maximal effort. 4. At the time of volitional fatigue when the individual stops, be sure to stop the watch. 5. Slow the treadmill and encourage gentle walking for 3-5 minutes immediately following the test. 6. Record the total time of the test below.

Section A: Results (to be completed by fitness professional)Result (Test Time): Member’s Name: Vitality ID:



Stage Time (min)

Speed (mph)

Grade (%)

1 0-3 1.7 10

2 3-6 2.5 12

3 6-9 3.4 14

4 9-12 4.2 16

5 12-15 5.0 18

6 15-18 5.5 20

7 18-21 6.0 22

8 21-24 6.5 24

9 24-27 7.0 26

10 27-30 9.5 28

min sec

Bruce Treadmill Protocol

Fitness Assessment Form Exhibit E

Expires 01/01/2014





The Modified Bruce Treadmill Protocol is a progressive exercise test to exhaustion, but is more suitable for high risk and sedentary individuals as the first three stages are completed at only 1.7 mph. Individuals should still be screened by standard risk assessment techniques and stratified accordingly. Given that the individual is classified as low risk, he or she may complete the Modified Bruce Protocol. If the individuals are high risk he or she must be cleared by a physician or a physician must be present.

Required materials: 1. Treadmill capable of reaching at least 6.0 mph and at least a 20% gradient 2. Stop watch

Optional materials: 1. Heart rate monitor for measurement of maximal heart rate

• Start the test at 1.7 mph and 0% grade. Increase the speed and grade thereafter according to the table on the left.

• Each stage is three minutes in duration.• Note that the grade increases in an irregular fashion for the first three

stages, and the speed increases only after the third stage.• Follow standard maximal exercise testing guidelines regarding

volitional fatigue to determine whether or not the measurement was valid.

Procedures: 1. Start the stopwatch at the beginning of the first stage. 2. Change the speed and grade of the treadmill according to the table above. Each stage is three minutes in duration. 3. The individual should be encouraged to go for as long as possible to achieve a true maximal effort. 4. At the time of volitional fatigue when the individual stops, be sure to stop the watch. 5. Slow the treadmill and encourage gentle walking for 3-5 minutes immediately following the test. 6. Record the total time of the test below.

Section A: Results (to be completed by fitness professional)Result (Test Time): Member’s Name: Vitality ID:


Fitness Professional Signature: Date of Signature:

min sec

Stage Time (min)

Speed (mph)

Grade (%)

1 0-3 1.7 0

2 3-6 1.7 5

3 6-9 1.7 10

4 9-12 2.5 12

5 12-15 3.4 14

6 15-18 4.2 16

7 18-21 5.0 18

Modified Bruce Treadmill Protocol

Fitness Assessment FormExhibit F





The One-mile walk test requires an individual to walk continuously and as fast as he or she can for one mile. The measured course should be flat, and ideally completed around a circuit such as an indoor or outdoor track. It is acceptable to complete this proto-col on a treadmill provided the individual is able to adjust the speed him or herself.

Although the aim is to go as fast as possible, it is very important that the individual walks for the entire test. Running is not permitted. This is an ideal test for older or sedentary individuals as it is only a walking test.

Required materials: 1. Treadmill or track 2. Stop watch

Optional materials: 1. Heart rate monitor

Procedures for using a track: 1. Measure the distance around the track or circuit and calculate the location of the start and finish lines. 2. Have the individual line up on the start line. 3. On your command, the individual should commence walking as you start the watch. 4. Record the walking time as the individual crosses the finish line. 5. Immediately find his or her radial pulse on his or her wrist and count for 15 seconds. 6. Record the number of beats you counted for the 15 second period, as well as the one-mile walking time.

Procedures for using a treadmill: 1. Have the individual stand on the treadmill. 2. Start the treadmill and the watch at the same time. 3. Keep track of the distance on the treadmill, stopping the watch when the individual reaches one mile. 4. Upon completion of one mile, instruct the individual to stop walking and remain standing while you find his or her

radial pulse on the inside of his or her wrist. 5. Count the heart rate for 15 seconds and record the 15 second value below.

Important notes: • The individual must remain still and standing during the measurement period following the test. • Any delay in measuring the heart rate after the test will produce an invalid result and require a retest on another

visit. Therefore, be sure to start measuring immediately after the test.

Section A: Results (to be completed by fitness professional)

Member’s Name: Vitality ID:



Weight: 15 Second Heart Rate Count: One-mile Walk Time:

lbs min sec

One-Mile Walk Test Protocol

Fitness AssessmentExhibit G


Physical activity plays an important role in prevention and health, and a fitness assessment is a way for you to engage with your physical activity beyond just being active. The results are descriptive---they describe your fitness level compared to others in your age and gender group. They do not impact your Vitality Age or affect your overall health risk.

The four different protocolsA fitness assessment measures different variables according to the specific protocol. The Vitality preferred protocol is the YMCA Step Test. It measures heart rate recovery following three minutes of stepping exercise. There is a well defined relationship between fitness level and the magnitude to which the heart rate decreases during the transition from exercise to rest. Higher fitness levels generally mean heart rate will decrease more rapidly following exercise cessation compared to lower fitness levels. The YMCA Step Test is based on this relationship. Therefore the lower the number of beats in the one minute following exercise, the higher the fitness level. Importantly, the YMCA Step Test is also a simple protocol that does not require expensive or large equipment. It can be completed in three minutes, which allows for many individuals to be tested in a short period of time and at a low cost.

Although the YMCA step test is best suited for the majority of individuals, in some instances the heart rate recovery might not be the best indicator of fitness. For those individuals one of the other protocols could be more suitable. The other tests are the one-mile walk test, the Modified Bruce Treadmill protocol and the Bruce Treadmill protocol. The one-mile walk test requires an individual to walk one mile as fast as possible, without running or jogging. Performance time, age, and body weight are then used to predict maximal oxygen uptake (VO2max). Both Bruce treadmill protocols are graded maximal exercise tests that use an equation to estimate VO2max according to the duration of the test. The longer the test duration, the higher the VO2max and corresponding fitness level.

Categorizing Fitness LevelsBecause fitness variables tend to change as we age, it is inappropriate to compare an older individual to a young one. The solution is to use normative rankings that are based on both age and gender. This is a standard way to compare relative rankings in a given population. Norms divide up the population into 100 groups, or percentiles, with 1% the values in each group, and help eliminate discrimination and compare people only to others in their age and gender group, since age and gender can affect most health-related measurements. Therefore, an older individual can have a different result than his or her younger peer but still be at the same fitness level. In this way your result is “adjusted” for age and gender.

Vitality uses published norms to assign the Fitness Level according to the results from each of the different protocols. We have stratified the published normative rankings for VO2max and heart rate recovery into five levels so that each level represents 20% of the population. For example, a Level 1 corresponds to the lowest 20% while a Level 5 represents the highest 20% of the population. The tables on the next page identify the thresholds for both VO2max and heart rate recovery for each fitness level.

Fitness AssessmentExhibit H


VO2max norms for the Bruce Protocol, Modi�ed Bruce Protocol, and One -mile walk test Source: Physical Fitness Assessments and Norms for Adults and Law Enforcement, 2009.

The Cooper Institute. www.cooperinstitute.org. MALE (Age groups)

Fitness Level Age 20-29 Age 30-39 Age 40-49 Age 50-59 Age 60+

5 51.1+ 48.3+ 46.4+ 43.3+ 39.6+ 4 45.6 - 51.0 44.1 - 48.2 42.4 - 46.3 39.0 - 43.2 35.6 - 39.5 3 41.7 - 45.5 40.7 - 44.0 38.4 - 42.3 35.5 - 38.9 32.3 - 35.5 2 38.0 - 41.6 36.7 - 40.6 34.8 - 38.3 32.0 - 35.4 28.7 - 32.2 1 <38.0 <36.7 <34.8 <32.0 <28.7

FEMALE (Age groups)

Fitness Level Age 20-29 Age 30-39 Age 40-49 Age 50-59 Age 60+

5 43.9+ 42.4+ 39.6+ 36.7+ 32.7+ 4 39.5 - 43.8 37.7 - 42.3 35.9 - 39.5 32.6 - 36.6 29.7 - 32.6 3 36.1 - 39.4 34.2 - 37.6 32.8 - 35.8 29.9 - 32.5 27.3 - 29.6 2 32.3 - 36.0 30.9 - 34.1 29.4 - 32.7 26.8 - 29.8 24.6 - 27.2 1 <32.3 <30.9 <29.4 <26.8 <24.6

Heart rate recovery norms for the YMCA Step Test Source: YMCA Fitness Testing and Assessment Manual, 2000.

MALE (Age groups)

Fitness Level 18-25 26-35 36-45 46-55 56-65 65+ 5 <86 <87 <89 <94 <95 <93 4 86-94 87-94 89-94 94-101 95-100 93-102 3 95-101 95-102 95-105 102-111 101-109 103-110 2 102-107 103-110 106-112 112-119 110-117 111-118 1 >107 >110 >112 >119 >117 >118

FEMALE (Age groups)

Fitness Level 18-25 26-35 36-45 46-55 56-65 65+ 5 <94 <93 <97 <102 <103 <103 4 94-102 93-101 97-104 102-110 103-111 103-112 3 103-110 102-110 105-112 111-118 112-118 113-121 2 111-120 111-119 113-120 119-124 119-127 122-126 1 >120 >119 >120 >124 >127 >126

fitness assessment form exhibit a

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