![]() |
| ||||||
|
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_______________________________________________
US Army Center for Health Promotion and Preventive Medicine. | |||||||