Fitness Assessment & Body Fat Test Request Form
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1FITNESS ASSESSMENT & BODY FAT TEST REQUEST FORM
Date
Name
________________________
____________________________________________________________
Phone
Email Address
_______________________
_____________________________________________________
Status: Student
UAB Employee
Colleague Member
Alumni
Household Member Retiree
Are you currently exercising? If so, please fill in the following:
Moderate
High
Light
INTENSITY OF WORKOUTS:
HOW MANY DAYS PER WEEK:
________________________
HOW MANY MINUTES PER SESSION:
________________________
Prefer male or female?
________________________
(We will work to accomodate all requests, but appointments are based on technician’s availability.)
Please mark which days and times are best for you to come in and have the test performed:
Monday
Tuesday
Wednesday
Thursday
Friday
8am - 9am
8am - 9am
8am - 9am
8am - 9am
8am - 9am
9am - 10am
9am - 10am
9am - 10am
9am - 10am
9am - 10am
10am - 11am
10am - 11am
10am - 11am
10am - 11am
10am - 11am
11am - 12pm
11am - 12pm
11am - 12pm
11am - 12pm
11am - 12pm
12pm - 1pm
12pm - 1pm
12pm - 1pm
12pm - 1pm
12pm - 1pm
1pm - 2pm
1pm - 2pm
1pm - 2pm
1pm - 2pm
1pm - 2pm
2pm - 3pm
2pm - 3pm
2pm - 3pm
2pm - 3pm
2pm - 3pm
3pm - 4pm
3pm - 4pm
3pm - 4pm
3pm - 4pm
3pm - 4pm
4pm - 5pm
4pm - 5pm
4pm - 5pm
4pm - 5pm
4pm - 5pm
Are you interested in Personal Training or any of our other wellness programs? If so, please name the
program/s:
Office Use Only
Date paperwork received
________________________
Additional Notes
________________________
________________________
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Parent category: Business