Baseline Assessment for Athletes
[Coaches: Please give this to new athletes as they start the program, and then every 6 months.
Please keep them on file for each kid in the program so you can compare over time.]
Name of Athlete:
Date of Birth (xx/xx/xx):
Height:
Weight:
Date Started CrossFit (xx/xx/xx):
Name of Local Steve's Club Program:
City, State:
Name of Coach:
Coach's Email:
FITNESS:
[Coaches: Please fill in the following benchmarks for each athlete. Scale as needed, be sure to
note the scaling in the results below. These don't have to be done the same day.]
Half "Cindy" (10 minutes, as many rounds as possible of: 5 Pullups, 10 Pushups, 15 Air Squats)
Total # of Rounds/Reps:
Scaling/Modifications:
400m time:
3RM Front Squat (lbs):
ATTITUDE:
[Coach: Please rank the athlete based on how they embody the Steve's Club values (1=poor,
10=great). For a baseline assessment, these can be left blank. If you don’t know, just put N/A]
________ Integrity: Do the right thing
________ Respect: Treat everyone well, play fairly
________ Improvement: Keep learning, growing, and getting better everyday
________ Teamwork: Help each other, cooperate, be loyal to the group
________ Support: Encourage and motivate others
________ Positivity: Have a good attitude, rebound from challenges, believe that you can
________ Discipline: Work hard, be dedicated, commit to excellence
________ Character: Strive to be the best you can be
________ Community: Give back, be a good role model, inspire others
Other comments from the coach:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
NUTRITION
[Coaches: Please have each athlete fill out this section, and remind them that it’s confidential.]
<< NO ONE BUT THE COACH WILL SEE YOUR ANSWERS >>
Do you eat 3 meals a day (at least)?
Never
Sometimes
Most of the time
Always
Most of the time
Always
Most of the time
Always
Most of the time
Always
How often do you eat breakfast?
Never
Sometimes
How often do you eat lunch?
Never
Sometimes
How often do you eat dinner?
Never
Sometimes
Do you eat the school lunch or bring your own?
School lunch
Bring your own
I don’t eat lunch
Do you get subsidized lunch at school?
No
Sometimes
Most of the time
Always
Circle the # of times per week:
How many times a week do you drink soda?
1-2
3-5
6-8
9-11
12-14
15+
9-11
12-14
15+
9-11
12-14
15+
How many times a week do you eat fast food?
1-2
3-5
6-8
How many times a week do you eat vegetables?
1-2
3-5
6-8
How many times a week do you eat protein (protein = any kind of meat, chicken, fish, eggs, tuna fish,
lunch meat)?
1-2
3-5
6-8
9-11
12-14
15+
Please circle what you think your body looks like:
(Schematic figural scale Collins 1991)
What did you eat yesterday?
Breakfast:
Lunch:
Dinner:
ENVIRONMENT/INTERNAL
[Coaches: Please have each athlete fill out this section, and remind them that it’s confidential.]
<< NO ONE BUT THE COACH WILL SEE YOUR ANSWERS >>
I can be good at something if I put in the effort
Not at all
No
Sometimes
Yes
Definitely
No
Sometimes
Yes
Definitely
Yes
Definitely
Yes
Definitely
Yes
Definitely
Yes
Definitely
Yes
Definitely
I try to be a good person
Not at all
There are people in my life that I care about
Not at all
No
Sometimes
I have been proud of myself in the past
Not at all
No
Sometimes
I have a supportive family environment
Not at all
No
Sometimes
I feel accepted by other kids at school
Not at all
No
Sometimes
I feel accepted by other kids in the neighborhood
Not at all
No
Sometimes
I feel accepted by other kids at Steve's Club
Not at all
No
Sometimes
Yes
Definitely
No
Sometimes
Yes
Definitely
No
Sometimes
Yes
Definitely
No
Sometimes
Yes
Definitely
No
Sometimes
Yes
Definitely
Yes
Definitely
I feel safe in my school
Not at all
I feel safe in my neighborhood
Not at all
I feel safe at my house
Not at all
I feel safe at Steve's Club
Not at all
Steve's Club is a supportive environment
Not at all
No
Sometimes