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contact@mpoweredsaskatoon.com
306 741 7286

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Consultation Form

Consultation Form:

Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
Yes
No
Do you feel pain in your chest when you do physical activity?
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
Yes
No
Do you have a bone or joint problem (for example, back, knee or hip) that could be made worse by a change in your physical activity?
Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition?
Yes
No
Do you know of any other reason why you should not do physical activity?
Yes
No
Medical History (any diagnosis/allergies/recent surgeries). List all medications (prescription/herbal and dosages)
Musculoskeletal History (any back/neck pain, injuries etc when? Treatment you’ve had and is it resolved?)
Activity History (describe your exercise routine in the last 3 mos in detail/wts, reps, cardio)
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