Functional Assessment Form
Please complete this assessment to evaluate your functional and strength abilities.
Full Name
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First Name
Last Name
Date Of Birth
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Day
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Month
Year
Date
Assessment Date
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Day
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Month
Year
Date
Functional Assessment Questions
Please answer Yes or No to the following questions.
Can you run 100 metres?
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Yes
No
Can you get up and down from a chair without using your hands and arms to help you?
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Yes
No
Can you swim 50 metres?
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Yes
No
Can you get up from the floor without help?
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Yes
No
How long does it take your heart rate to normalise after running/jogging 100 metres?
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1–2 min
2–3 min
3–4 min
4–5 min
Strength & Functional Movement Questions
Please answer Yes or No. If Yes, provide additional details where requested.
Can you do push ups?
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Yes
No
If Yes, what type of push-up can you do?* select 1 answer
Wall push-up
Knee push-up
Modified standard push-up
Standard push-up
If Yes, how many push-ups can you do in 1 minute?
Select the answer that corresponds to how many push-ups you can do in 1 minute:
Female: 5+
Female: Less than 5
Male: 10 +
Male: Less than 10
Can you do a squat?
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Yes
No
If Yes, how many squats can you do in 1 minute?
Select the answer that corresponds to how many squats you can do in 1 minute:
Female: 10+
Female: Less than 10
Male: 15 +
Male: Less than 15
Can you walk up 10 stairs?
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Yes
No
Can you do a wall sit?
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Yes
No
If Yes, how long can you hold a wall sit? (in seconds)
Can you do a burpee?
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Yes
No
If Yes, how many burpees can you do in 1 minute?
Select the answer that corresponds to how many burpees you can do in 1 minute:
Female: 5+
Female: Less than 5
Male: 10 +
Male: Less than 10
Total score out of 30:
Submit Assessment
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