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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
_____________________________________________
Address
______________________
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