Introductory Session Contents
 
Targeting Fitness

Recommendation For Physician Referral (post fitness assessment)

It has come to our attention that you have a health concern in the following area. Please call your health care provider as soon as possible to schedule an appointment for a consultation and check-up.

__________________ CHOLESTEROL

__________________ BLOOD PRESSURE

__________________ DIZZINESS/ BLURRED VISION

__________________ RESPIRATORY DISTRESS

__________________ JOINT PAIN WITH EXERCISE TESTING

__________________ MUSCULAR PAIN WITH EXERCISE TESTING

__________________ CHEST PAIN WITH EXERCISE TESTING

__________________ OTHER


I GIVE MY PERMISSION FOR YOU TO CONTRACT MY HEALTH CARE PROVIDER ABOUT THE ABOVE MENTIONED SYMPTOM (S).

NAME____________________________________________________

PROVIDER________________________________________________

PHONE ___________________________________________________

SIGNATURE_______________________________________________

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US Army Center for Health Promotion and Preventive Medicine.