American Association of Sports Medicine Technicians
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Diabetic Fitness Testing

For individuals with Type 2 Diabetes, Pre-Diabetes, or Metabolic Syndrome
    CHECK-IN
    mm/dd/yy
    (If applicable.)
    Max file size: 20MB
    Face
    MEDICAL HISTORY
    YY.MM
    In Feet' & Inches ', to the nearest whole inch.
    In Pounds, to the nearest whole pound.
    In Inches, to the nearest half-inch.
    Mark all that apply.
    mg/dl
    HH:MM
    CLEARANCE
    INFORMED CONSENT
    PRE-PARTICIPATION SCREEN
    Required only if a follow-up test.
    Required only if a follow-up test.
    Required only if a follow-up test:
    Required only if a follow-up test. Report as a %: actual doses over prescribed doses
    FITNESS TESTS
    Walk/Jog (Cardio) - Do A or B, not both.
    A: Treadmill
    mm:ss
    Picture
    B: Track
    mm:ss
    mm:ss
    Picture
    Squats (Legs)
    (1-min Cap)
    # of Reps in 1 minute
    Picture
    Leg-Raises (Abs)
    (1-min Cap)
    # of Reps in 1 minute
    Picture
    Push-Ups (Arms)
    (1-min Cap)
    # of Reps in 1 minute
    Picture
    Total Score x 5 = Official Med-Fit Score as a %
    On a Scale of 1-10, 10 being completely exhausted.

    ​OptiHealth Exercise Rx Dosing Guidelines

    Picture
    Exercise Rx:
    # of Weeks
Submit
AASMT
Because Exercise is Powerful Medicine and Fitness is the Cure.

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