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Sports Medicine Consultation
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Indicates required field
Medical-Fitness Facility:
*
Date:
*
MM/DD/YY
Client's Name:
*
First
Last
Phone #:
*
Medical Concern:
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Health Promotion
Risk Reduction
Disease Reversal
Other
Mark all that apply.
If "Other" above, explain below:
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Gender:
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Male
Female
Date of Birth:
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MM/DD/YY
Age:
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YY.MM
Family Profile:
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Home > Spouse > Children > Parents
Occupation:
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Special Interests:
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Physical Activity:
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Formal > Informal
Gym Membership(s):
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General Eating Pattern:
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Standard American Diet
Modified SAD
Pescatarian
Lacto-Ovo-Vegetarian
Vegetarian (Vegan)
Whole Plant Foods
Chronic Lifestyle Diseases:
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Overweight / Obesity
High Blood Pressure
High Cholesterol
High Blood Sugar (Pre-Diabetes)
Metabolic Syndrome
Type 2 Diabetes
Heart Disease
Cancer
Other
Mark all that apply.
If "Other" above, specify below:
*
Current Medications:
*
For lifestyle-related medical conditions only.
Client's Perspective on Health Status:
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Excellent
Good
Fair
Poor
Critical
If mismatched, explain to client until agreeable.
Client's Perspective on Health Prognosis:
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Improving
Stable
Worsening
If mismatched, explain to client until agreeable.
Impressions:
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Recommendations:
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Research Enrollment
Body Composition Analysis
Fitness Analysis
Blood Chemistry Analysis
Therapeutic Fitness Training
Nutrition Analysis
Lifestyle Medicine Consultation
Medical Integration
Other
Mark all that apply.
If "Other" above, specify below:
*
Availability:
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Day / Week / Month / Year
Follow-Up:
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# of Weeks or Months
Sports Medicine Technician:
*
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