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Los Angeles & Orange County: 949.245.6239

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Aging is Certain, Decline is Not.

Intensity Level Self-Assessment

This assessment will assist in choosing the exercise class that will work best for you. To do this, we need to know a little more about you, your activity level, your exercise history, and your symptoms.

Choose 1 answer for each question below. Add up your points to determine your score using the scoring criteria at the bottom of the page.

First name*

Last name*

Date*

Month

Day

Year

1. Have you had two or more falls in the last 6 months? *

Yes = 1 point

No = 0 points

2. On a scale of 0-100%, how confident are you in your ability to exercise safely?*

More than 70% confident = 0 points

Less than 70% confident = 1 point

3. Can you get down and up from the floor by yourself, with or without using a chair?*

Yes = 0 points

No = 1 point

4. Do you need an assistive device or help from another person for walking?

Yes = 1 point

No = 0 points

5. Do you ever feel dizzy or lightheaded when you stand up from sitting or lying down?

Yes = 1 point

No = 0 points

6. Do you have freezing of gait when you turn, are in a hurry, or do more than one thing at a time?

These are episodes where you feel like your feet are stuck to the floor when you are trying to walk, trembling in your feet followed by short, small steps, or even total immobility for a few moments?*

Yes = 2 points

No = 0 points

7. Do you have pain, joint limitations, major medical conditions, or other neurological conditions that may interfere with your ability to exercise without making adjustments? *

Yes = 1 point

No = 0 points

8. Using the definitions below, which of the intensity levels below best characterizes your average physical activity for the last 3 months?*

Sedentary or Low Intensity, meaning that your physical activity is limited to no more than slow walking and limited leisurely activities = 4 points

Moderate Intensity, meaning that you exercise at a pace where you can talk but couldn’t sing, such as brisk walking, light biking, water exercise, and dancing = 2 points

Vigorous Intensity, meaning that your activity is at a pace where you can't talk and you may be out of breath, such as jogging, swimming, tennis, and fast biking = 0 points

Interpreting Your Score: _____

0-5 Points = Moderate to High Intensity

6-12 points = Low to Moderate Intensity

San Diego County, CA

7551 Convoy Ct. San Diego, CA 92111

o: 619.263.0239

f: 619.858.2210

e: info@reneu-health.com

Orange County, CA

Orange County, CA

o: 619.263.0239

c: 949.245.6239

e: info@reneu-health.com

Los Angeles County, CA

Los Angeles County, CA

o: 619.263.0239

c: 949.245.6239

e: info@reneu-health.com

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