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