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Medical-Fitness Assessment
As an OptiHealth Coach, you may use the form below to record your client's fitness tests and issue their Exercise Rx's.
*
Indicates required field
Name:
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First
Last
Email:
*
Phone #:
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Include Area Code
Age:
*
yy.mm
Gender:
*
Male
Female
Exercise Rx:
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Follow-Up Fitness Assessments Only: Doses/Week
Days / Week:
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Doses (Min) / Day:
*
= Doses (Min) / Week:
*
% Adherence:
*
Follow-Up Fitness Assessments Only
Hate Scale:
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1 to 10
Why hate?
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Time
Boring
Pain
Sweat
SoB
DOMS
Futility
Mark all that apply.
Other:
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PRE-PARTICIPATION SCREEN
Screen:
*
Not Indicated
Negative (Passed)
Positive (Failed)
INFORMED CONSENT
Consent:
*
Not Indicated
On-File
Refused
FITNESS TESTS
Walk/Jog (Cardio)
A: Traedmill
MPH:
*
Time:
*
mm:ss
Cardio Score A
*
RPE:
*
B: Track
220 yards:
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mm:ss
880 yards:
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mm:ss
Cardio Score B:
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RPE:
*
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:
*
# 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 4 = Official Med-Fit Score as a %
OptiHealth Exercise Rx Dosing Guidelines
EXERCISE RX
Doses/Session:
*
Usually 2-10
Sessions/Day:
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Usually 3
Days/Week:
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Usually 6
= Doses/Week:
*
Goal: 150+
Follow-Up:
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# of Weeks (usually 4-12)
Daily Exercise Sessions
Exercise Dose-Equivalents
Additional Instructions:
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Lifestyle Medicine Clinic
*
Date:
*
mm/dd/yy
Lifestyle Medicine Technician:
*
First
Last
Technician's Email:
*
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