Home
Contact Us
About Us
>
Disclaimer
Privacy Policy
Professionalism
Certification
Membership
Fitness Analysis
*
Indicates required field
Medical-Fitness Facility:
*
Date:
*
MM/DD/YY
Client's Name:
*
First
Last
Phone #:
*
Screening for Medical Clearance:
*
Medical Clearance NOT Required
Medical Clearance on File
Front Photo:
*
Max file size: 20MB
Full Body - Front
Side Photo:
*
Max file size: 20MB
Full Body - Right Side
Medical-Fitness Score:
*
% - Required only if a follow-up analysis.
Score Date:
*
MM/DD/YY - Required only if a follow-up analysis.
Exercise Rx Adherence Level:
*
% of 21 FULL sessions per week. Required only if a follow-up analysis.
Adherence Verification:
*
Yes
No
Required only if a follow-up analysis.
Type of CPV Fitness Test:
*
Track
Treadmill
Cardio-Pulmonary-Vascular Fitness Score:
*
Leg Muscles Fitness Score:
*
Abdominal Muscles Fitness Score:
*
Arm Muscles Fitness Score:
*
Total Medical-Fitness Score:
*
Impression:
*
Exercise Rx:
*
#'s for Doses / Sessions / Days / Weeks
Recommendations:
*
Sports Medicine Consultation
Therapeutic Fitness Training
Nutrition Analysis
Lifestyle Medicine Consultation
Medical Integration
Other
Mark all that apply.
If "Other" above, specify below:
*
Up-Dates:
*
Score Card
Exercise Rx
TFT Program
Rx Exercise Log
Graduation Plan
Other
Mark all that apply.
Follow-Up:
*
# of Weeks or Months
Sports Medicine Technician or Assistant:
*
Submit