Patient History Form - Free Download | Page 4
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Patient History Form Page 4
Medical History Form 3
Exercise Program Assessment
Staff Use
Body Fat
% Ht
Abd Girth
Wt
CARDIO
(check all that apply)
Time (min)
Frequency (per wk)
Intensity
STRENGTH
Resistance /
weight
# reps / set # sets
Frequency (per week)
Elliptical
Bike (Outside)
Bike (Stationary)
Run
Walk
Aerobic Class
Cross Country Ski
Swim
Row
Stair
Other
Patient Name:
Date:
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Low Med High
Jog
Calves
Hamstrings
Quadriceps
Hips
Mid-Section
Forearms
Eliceps
Lower Back
Chest
Triceps
Shoulders (Deltoids)
Upper Back
Triceps
Biceps
Shoulders (Deltoids)
Upper Back
Lower Back
Chest
STRETCHING/
FLEXIBILITY
Frequency
(per week)
Time held per stretch
# stretches/
set
page 4.
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