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Therapeutic Fitness Training Report
*
Indicates required field
Medical-Fitness Facility:
*
Client's Name:
*
First
Last
Phone #:
*
Referral Source Category:
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Select One
Friend or Relative
OptiHealth Volunteer
Healthcare Professional
Church Health Ministry
School Health Program
Corporate Health Program
Other
Intra-Category Specification:
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Entry Point:
*
Select One
Free & Fun Fitness Training
Sports Medicine Consultation
Body Composition Analysis
Fitness Analysis
Therapeutic Fitness Training
Nutrition Analysis
Lifestyle Medicine Consultation
Diabetes Reversal Consultation
Start Date:
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MM/DD/YY
Graduation Date:
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MM/DD/YY
Front Photo:
*
Max file size: 20MB
Full Body - Front
Side Photo:
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Max file size: 20MB
Full Body - Right Side
OptiHealth Pledge:
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%
Challenge Time:
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A/B - MM:SS
Total Medical-Fitness Scores:
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Start - End
CPV Fitness Scores:
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Start - End
Leg Muscles Fitness Scores:
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Start - End
Abdominal Muscles Fitness Scores:
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Start - Finish
Arm Muscles Fitness Scores:
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Start - End
Average Exercise Rx Adherence Level:
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% of Rx'd Exercise Sessions.
Therapeutic Fitness Training:
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None
Out-Sourced
Online Sessions
Live Sessions
Minimal
Partial
Full
Mark all that apply.
Medical-Nutrition Scores:
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Start - End
Change in Weight:
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Start - End
Change in WC:
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Start - End
Change in BMI:
*
Start - End
Average Nutrition Rx Adherence Level:
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% of Rx'd WPF Meals
Adherence Verification:
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Exercise only
Nutrition only
Exercise & Nutrition
Neither
Research Participant:
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Yes
No
Adjunctive TLC Programs:
*
Medical Integration:
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None
Partial
Full
Client's Testimonial:
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Impression:
*
Recommendations:
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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
Mark all that apply.
If "Other" above, specify below:
*
Follow-Up:
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# of Months
Sports Medicine Technician:
*
Submit