Patient's Phone Number:
Reason for referral:
Patient may engage in fitness assessment(s) (including cardiovascular endurance, muscular strength & endurance, upper & lower body flexibility, balance & gait), group movement classes, and an individualized exercise program designed by an exercise professional.
Assessment and/or exercise restrictions (if any):
Patient may participate in an onsite weight management or other nutritional counseling program if they choose.
Nutrition Restrictions (if any):
Health Care Provider's Name:
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