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