Daisey Physical Therapy and The Center for Human Performance

Cervical/Neck

Shoulders/Rotator Cuff

Knees/Patella

Hips

Elbow and Wrist

Ankle and Foot

DECREASE YOUR OVERALL BODY FAT

First Name:
Age:
Gender:

Height:	feet inches
Weight:	pounds
Total Cholesterol Level:	mg/dl Unsure
Resting Heart Rate: (How do I find my resting heart rate?)	Beats per minute (bpm)
Resting Blood Pressure:	over mmHG Unsure
When was the last time you exercised for a sustained period of at least 3 months?

Check which exercises you are most interested in adding to your program:

Stationary bike
Recumbent bike
Outdoor bike
Treadmill walking
Treadmill jogging
Outdoor walking
Outdoor jogging

Stairclimber
Elliptical bike
Cross Country Ski simulator
Upper body ergometer
Rowing machine
Swimming
Aerobics

Which days of the week are you planning on exercising?

Monday
Tuesday
Wednesday
Thursday

Friday
Saturday
Sunday

Check any of the areas in which you experience recurrent pain (mild to severe) or any area in which you have been diagnosed with an injury or medical condition:

Lower Back
Middle Back
Hip (groin)
Ankle/Foot

Neck
Shoulder
Knee

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Copyright © 2006, Daisey Physical Therapy & Sports Medicine Inc. All rights reserved.
The information contained in this web site is not a substitute for in-person, hands-on medical advice
or treatment. Daisey Physical Therapy recommends you consult with your physician or health care professional.