Client Name: Date:
Note to Physician:
The above ecoachjoe.com client has requested a general fitness assessment and exercise program prescription.
Health history information about this individual precludes me from continuing without your consent and
recommendations. The general fitness assessment includes a measured seated heart rate, blood pressure,
muscular endurance testing involving push-ups and sit-ups, and muscular battery of absolute strength or a
fifteen repetition maximum. In addition, estimated body composition is analyzed using skin fold measurements
or the futrex infrared and estimated oxygen uptake is analyzed using the YMCA. sub-maximal bicycle protocol.
Please complete this form in order for the fitness testing to be conducted and an exercise program prescribed.
I , authorize my physician to release the following information to ecoachjoe.com
training web site.
1. Are there contraindications to exercise? YES NO
If yes, please explain.
2. Is cardiovascular conditioning recommended? YES NO
Maximum Heart Rate not to be exceeded: beats/minute
3. Are there any contraindications to flexibility training? YES NO
If yes, please describe.
4. Areas of special attention:
Arms/Shoulders
Lower Back
Upper Back
Legs/Knees
Neck
Other
5. Please describe any recommendations or restrictions regarding an exercise program:
PLEASE PRINT CLEARLY OR TYPE:
Physician Name
Address
Phone ()
Physician's Signature ________________________________________ Date __________________
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