RMR PARTICIPATION

Schedule a consultation (609) 653-4900

You can choose to download and fill out the form manually, or fill out the online form below and hit Submit.

Metabolic Rate Testing Participation Form

* Indicates required field

Has a doctor ever said 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 are not doing physical activity? *

Yes No

Do you lose your balance because of dizziness or do you ever lose consciousness? *

Yes No

Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? *

Yes No

Do you have a bone or joint problem that could be made worse by a change in your physical activity? *

Yes No

Do you know of any other reason why you should not do physical activity? *

Yes No

**If you are over 69 years of age, and you are not used to being very active, check with your doctor

Please list all medications (including herbs and vitamins) that you are currently taking:

Name of medication, dosage and reason you are taking: *

Do any of your medications affect your heart rate? If you are uncertain, please consult your physician. *

Date of Birth *

Age *

Date *

Participant's Name *

First

Last

Witness Name *

First

Last

You may be asked to sign this document during your office visit with Nancy Adler Nutrition as well as obtain the signature of your witness.

Submit

Nancy Adler
1201 New Rd.
Suite 131
Cornerstone Executive Center
Linwood, NJ 08221

Telephone: 609-653-4900
Fax: 609-601-3217
Email: [email protected]