Dear Dr. __________________________,

Your patient __________________________, has requested to participate in an exercise program with us. The program will consist of a combination of aerobics conditioning, resistive training, as well as stretching and mobility exercises. Please indicate and check the appropriate box for your patient:

( ) No contraindications for participation in general exercise program
( ) Participation in exercise program is recommended with the following
restrictions or modifications ____________________________________________________

( ) I do not recommend participation in a general exercise program at this time
Please list any medications your patient is taking, the reason for taking them, and whether they have any effect on blood pressure, heart rate, or exercise response and what that response would be_________________________________________________

If available from your patient's last visit or exam, please provide the following:

Resting Blood Pressure ____/____/____mm Hg Resting Pulse ____bpm

Total Cholesterol ________mg/dl HDL's______mg/dl LDL's______mg/dl

Physician's Signature

Date signed



*Please print this form and complete it. Bring it with you on your next visit to LifeForce Fitness.