1461 A First Avenue #169, New York City, New York 10021-2201 — Phone (212)717-2294

Dear Dr. __________________________,

Your patient __________________________, has requested to participate in an exercise program with us. The program will consist of a combination of aerobics conditioning, resistive training, as well as stretching and mobility exercises. Please indicate and check the appropriate box for your patient:

( ) No contraindications for participation in general exercise program

( ) Participation in exercise program is recommended with the following restrictions or modifications __________________________________________________________________________________________________
__________________________________________________________________________________________________

( ) I do not recommend participation in a general exercise program at this time

Please list any medications your patient is taking, the reason for taking them, and whether they have any effect on blood pressure, heart rate, or exercise response and what that response would be_________________________________________________

__________________________________________________________________________________________________

If available from your patient's last visit or exam, please provide the following:

Resting Blood Pressure ____/____/____mm Hg Resting Pulse ____bpm

Total Cholesterol ________mg/dl HDL's______mg/dl LDL's______mg/dl

_____________________________________________

Physician's Signature

______________________

Date signed ____________________________________________

Address ______________________

Phone ________________________

Thank you very much for taking time to fill this form out.

Sincerely,

Underdog Personal Fitness