Therapeutic Fitness Training Report

* Indicates required field

Medical-Fitness Facility: *

Client's Name: *

First

Last

Phone #: *

Referral Source Category: *

Intra-Category Specification: *

Entry Point: *

Start Date: *

Graduation Date: *

Front Photo: *

Max file size: 20MB

Side Photo: *

Max file size: 20MB

OptiHealth Pledge: *

Challenge Time: *

Total Medical-Fitness Scores: *

CPV Fitness Scores: *

Leg Muscles Fitness Scores: *

Abdominal Muscles Fitness Scores: *

Arm Muscles Fitness Scores: *

Average Exercise Rx Adherence Level: *

Medical-Nutrition Scores: *

Change in Weight: *

Change in WC: *

Change in BMI: *

Average Nutrition Rx Adherence Level: *

Adherence Verification: *

Exercise only Nutrition only Exercise & Nutrition Neither

Research Participant: *

Yes No

Adjunctive TLC Programs: *

Medical Integration: *

None Partial Full

Client's Testimonial: *

Impression: *

Recommendations: *

Get Certified as an OptiHealth Coach Get certified as a Sports Med-Tech Assistant Get certified as a Sports Medicine Technician Get certified as a Sports Medicine Specialist Get certified as a Lifestyle Med-Tech Assistant Get certified as a Lifestyle Medicine Technician Get certified as a Lifestyle Medicine Specialist Other

If "Other" above, specify below: *

Follow-Up: *

Sports Medicine Technician: *

Submit