Patient History Form - Free Download | Page 5
This form is provided by Inova Health System.
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Patient History Form Page 5
Medical History Form 3
Date:
Patient Name:
Exercise Program Assessment
page 5
Gym Member Gym equipment @ home/work
Do you currently work with a personal trainer Yes No
If yes, frequency:
Injuries/Restrictions
Increase strength/endurance
Stress management
Disease Management
Type
Race Event
Other
Barriers to exercise:
FITNESS GOALS
Type
Type
Additional information you wish to share:
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