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Example of the REPORT
QUESTIONNAIRE "Be tall, graceful and strong"
Instructions on how to fill out the QUESTIONNAIRE
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MBF Method Corp.
156-11 Aguilar Ave. Suite P 3 Flushing, NY 11367
Phone (718) 380-4750; (718) 380-4745; Fax (718) 380-4597
E - MAIL mbaranov@hotmail.com

QUESTIONNAIRE "BE TALL, GRACEFUL, AND STRONG"
(for children from birth to 18 - 20)

Please note follow the instructions before filling out this form on the description of the method of measuring physical fitness and functional status.
You can type necessary data on into the application, then print it out. Or you can clearly fill in the data by hand after printing the application out.

PERSONAL INFORMATION:
First Name:
Last name:
Date of Birth: (month)
(day)
(year)
Sex:
Address: (street and apt. number)
City:
Country:
State: (2 letters)
Zip Code:
Phone:
-mail:
Date of test execution: (month)
(day)
(year)
HEIGHT AND WEIGHT:
Mother's height: (feet & inches or cm)
Father's height: (feet & inches or cm)
Your height: (feet & inches or cm)
Your weight: (lbs or kgs)
BODY TYPE: ectomorph
mesomorph
endomorph
Body proportions:
Circumferences (in or cm):

(f) - only for female;
(f, m) - for female and male;
(m) - only for male
Neck: (f) Thigh: (f, m)
Breast: (f) Calf: (f)
Waist: (f, m) Upper Arm: (f,m)
Buttocks: (f) Chest: (m)
HEART RATE in rest: (beats/min)
FVC (Forced Vital Capacity):
(in ml.)
BLOOD PRESSURE (mm Hg ): (Systolic Blood pressure)
(Diastolic Blood pressure)
STATIC FORCE Right hand: (lbs., or kgs)
STATIC FORCE Left hand: (lbs., or kgs)
Fitness Level, Fill 1 or 2
1. Integral test:
2. Medical or personal grade regarding the tests:
WHICH LANGUAGE YOU WANT TO RECEIVE THE REPORT:
IN WHICH MEASUREMENTS:
REPORT YOU CAN RECEIVE THIS, BY SENDING THE FILLED OUT QUESTIONNAIRE ALONG WITH A CHECK OR MONEY-ORDER IN THE SUM OF $39 TO MBF METHOD CORP to the address of
MBF METHOD CORP. 156-11 Aguilar Ave. Suite P3 Flushing, NY 11367

(c) 2001 MBF Method Corp.