Exercise Program Prescription And Letter Of Medical Necessity

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SPORTS PERFORMANCE AND REHABILITATION CENTER
SPARC 1765 Old West Broad St, Bldg 3, Athens, GA 30606
Phone: 706-286-7338 | Fax: 706-546-0793
Exercise Program Prescription and Letter of Medical Necessity
Patient Name ___________________________________________ DOB______/______/______Date ___________
Email______________________________________________________________________________________
MEDICAL CONDITION
Dx:
 Hypertension
 Diabetes Mellitus
 Coronary Artery Disease
 Peripheral Vascular Disease
 Osteoarthritis
 Obesity
 Low Back Pain
 COPD/Emphysema
 Asthma
 Osteoporosis
 CHF
 Depression
 Other___________________
Aerobic Activity: Type:
 Walk
 Run
 Bike
 Other:________________________________________
Intensity:  Light
 Moderate
 Vigorous
Strength Training:  ExtremitIes Only
 Core Only
 Extremities & Core
 Progressive Strength Training Program
SPARC SERVICES
Sports Performance: Youth, adult, & elite athlete programs geared towards training sport specific energy systems, mobility, & strength
General Fitness Programs: Private, Small Group, & Group Fitness training programs that are effective for fat loss, strength gain,
cardiovascular endurance, & promoting proper joint function for adults of any age or fitness level
Physical Therapy: Treatment for individuals who experience pain or joint dysfunction
Other services:
Massage Therapy: Deep tissue, Thai, and sports massage techniques effective for restoring mobility, breaking down scar
tissue, & reducing pain & anxiety
Performance Lab: Body composition, VO2 max, lactate threshold, & resting metabolic rate testing, as well as gait
analysis & concussion screening
Golf Program: Swing training or assistance returning to golf after surgery led by a DPT/TPI certified resource designed
to address impairments & teach efficient techniques
Fax your completed form with a cover sheet to (706)546-0793, Attention: SPARC, Subject: Patient name & phone #
I personally have evaluated this patient and clear them to participate in an exercise program:
Print:____________________________Sign:_______________________ Date:___________
ank you for prescribing exercise!

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