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Diabetic Fitness Testing
For individuals with Type 2 Diabetes, Pre-Diabetes, or Metabolic Syndrome
CHECK-IN
*
Indicates required field
Location:
*
Date:
*
mm/dd/yy
Sports Med-Tech Assistant:
*
Sports Medicine Technician:
*
Participant:
*
First
Last
Organization:
*
(If applicable.)
Photo:
*
Max file size: 20MB
Face
MEDICAL HISTORY
Age:
*
YY.MM
Gender:
*
Select One
Male
Female
Height:
*
In Feet' & Inches ', to the nearest whole inch.
Weight:
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In Pounds, to the nearest whole pound.
Waist Circumference:
*
In Inches, to the nearest half-inch.
Medical Conditions:
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Type 2 Diabetes
Pre-Diabetes
Metabolic Syndrom
High Blood Pressure
High Cholesterol
Cardiovascular Disease
None of the Above
Mark all that apply.
Other:
*
Year of Diagnosis:
*
Last Blood Sugar Level:
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mg/dl
Hours since last meal:
*
HH:MM
CLEARANCE
Informed Consent:
*
Not Indicated
On File
Refused
INFORMED CONSENT
Pre-Participation Screen:
*
Not Indicated
Negative (Pass)
Positive (Fail)
PRE-PARTICIPATION SCREEN
Test #:
*
Previous Test Score:
*
Required only if a follow-up test.
Prescribed Doses/Week:
*
Required only if a follow-up test.
Actual Doses/Week:
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Required only if a follow-up test:
Compliance:
*
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
MPH:
*
Time:
*
mm:ss
Cardio Score A
*
B: Track
220 yards:
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mm:ss
880 yards:
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mm:ss
Cardio Score B:
*
Squats (Legs)
Consecutive Reps:
*
(1-min Cap)
1-Min AMRAP:
*
# of Reps in 1 minute
Leg Score:
*
Leg-Raises (Abs)
Consecutive Reps:
*
(1-min Cap)
1-Min AMRAP:
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# of Reps in 1 minute
Abd Score:
*
Push-Ups (Arms)
Consecutive Reps:
*
(1-min Cap)
1-Min AMRAP:
*
# of Reps in 1 minute
Arm Score:
*
Total Score:
*
% Score:
*
Total Score x 5 = Official Med-Fit Score as a %
RPE:
*
On a Scale of 1-10, 10 being completely exhausted.
OptiHealth Exercise Rx Dosing Guidelines
Exercise Rx:
Doses/Session:
*
Sessions/Day:
*
= Doses/Day:
*
Days/Week:
*
= Doses/Week:
*
Follow-Up:
*
# of Weeks
Referred to a Med-Fit Clinic?
*
Yes
No
Enrolled in "Diabetes Undone" ?
*
Yes
No
Submit
