Physician Communication Letter 1

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Date

2

Client Name

First Name

Last Name

3

Primary Goal

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Secondary Goal

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Tertiary Goal

6

Do you have any Chronic Conditions?

YESNO

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Condition 1

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Condition 2

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Condition 3

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Doctor Name

First Name

Last Name

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Doctor Street Address Line 1

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Doctor Suite or Office Number

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Doctor City

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Doctor State

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Doctor Zip Code

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Are you currently on any medications?

YESNO

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Medication 1

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Medication 2

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Medication 3

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Dear Dr. {doctorName},

As part of our Physician’s Communication Program, I am writing to notify you that your patient, {clientName}, is participating in a personal fitness training/exercise program with us, Elect Wellness, and to request your guidance regarding known specific medical condition(s)/medication(s) so that we may safely provide our services. {clientName} has signed this form on page two, authorizing your release of this information to us. Please complete this form and return to us either by email to info@electwellness.com or by mail. Should you have any questions, I can be reached directly at 888-330-9355. Thank you for your attention to this matter.

{clientName}’s primary goals in utilizing our services are:

- {primaryGoal}
- {secondaryGoal}
- {tertiaryGoal}

To achieve these goals, {clientName} is performing the following activities under the direct supervision of a certified fitness professional:

- Corrective exercise that balances agonist/antagonist muscle symmetry across joints to improve both posture and function, while reducing risk of injury
- Resistance training incorporating slow but steady progressive overload and gradual reduction of rest intervals to improve strength and metabolism
- Active aerobic conditioning, progressing from simple bodyweight moves, to walking and stepping, jogging and jump rope, agility drills, kickboxing, etc. (only as safely ready)

We are aware of the following health conditions and/or medical diagnosis:
- {condition1}
- {condition2}
- {condition3}

If your patient is taking medications that will affect his or her heart rate response to exercise, please indicate the manner of the affect (raises, lowers, or has no affect on heart rate response, etc.):

Medication(s) we are aware of: Effect(s) you want us to be aware of:

{medication1}:
_______________________________
{medication2}:
_______________________________
{medication3}:
_______________________________

Please identify any recommendations or potential restrictions that are appropriate for your patient in the program listed above.

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I authorize my physician to respond to this.Patient's signature & date:

Clear