Date: ___________

Dear Doctor ________________________:

My Client, ________________________ has hired me as their personal trainer and named you as their primary health care provider. They would like to start a cardiovascular and/or resistance-training program. The program will involve the following:

Type of exercise: ________________________

Frequency: ________________________

Duration: ________________________

Intensity level of exercise: ________________________

Please identify any medication that will affect their heart rate and/or blood pressure.

Type of medication: ________________________

Effects of medication: ________________________

Please give any instructions or restrictions pertaining to your client participating in an exercise program.

_____________________________________________________________

_____________________________________________________________

Clients name: ________________________has been approved to begin an exercise program following the guidelines provided.

Doctor's signature: _______________________ Date: ___________

Phone: ________________________ Fax: _________________________

Thank you,

Your name ___________________________________________________

Contact information _________________________________________