In Motion Exercise Referral Form Please fill out or download the following referral form for the In Motion - Bone and Joint Health Program. Download Referral Form Patient Name Patient Address Address City/Town ZIP/Postal Code Patient Phone Number Patient Birthday Referring Diagnosis Date of Diagnosis Treatment Treatment - None -SurgeryMedicationPhysiotherapyOther… Enter other… Surgery Date Relevant Past Medical History Relevant Past Medical History - None -DiabetesPADCardiacHypertensionOther… Enter other… Is Patient on Beta-Blocker Medication - None -YesNo Recommended to measure Blood Glucose Pre and Post Exercise - None -YesNo Risk Factors / Side Effects Risk Factors / Side Effects - None -FracturesFalls in last yearLost 2 cm or more (3/4") in heightLost 6 cm or more (2 1/2") in height in adulthoodOther… Enter other… Excercise Contradictions, Limitations or Restrictions - None -Surgical PrecautionLifting RestrictionGait AidHip / Knee Restrictions post-surgery Financial Assistance Required Other Notes Name of Physician Physician Phone Number Today's Date Leave this field blank This information contained within this referral has been discussed with the patient.
