Medical Certification To the examining physician: Please supply the following information requested in all four parts below. Name of Patient: ________________________________________ Age: __________ Height: __________ Weight:
__________ 1. General Health: Please circle choice(s) then explain below:
(b) conditions requiring prescription medication or special dietary practices (e.g. diabetes, epilepsy, hypertension, etc.) (c) conditions requiring periodic supervision of a physician while here at the Center (d) allergic to drugs/ medication? Specify ___________________________________________________________ ___________________________________________________________ ___________________________________________________________
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(b) Has the patient received treatment for alcoholism? If so, specify dates. ___________________________________________________________ ___________________________________________________________ ___I have given the client a thorough medical and in my clinical judgment this person is fit to attend. ___I feel there is a need for an exercise test to evaluate asymptomatic coronary disease. The physician is asked to share this with the client. The successful completion of the test will be required for admission. ___Although I endorse this client's participation in the program the following limitation(s) should be placed on this person's physical activities. (work, hikes, athletics, etc.) ___I do not feel the client's health would permit her/him to attend the program. Date:______ Signed: __________________ Phone: ( _____ ) _____-______
Please mail or fax to ADMISSIONS at: SANGRE DE CRISTO CENTER |