Medical Clearance Form - Recsports printable pdf download

Medical Clearance Form - Recsports

Medical Clearance Form

Dear Physician:

Date ___/___/______

Your patient, ___________________________, has applied to participate in one-on-one

personal training with the University of Tennessee Student Recreation Center for

Students, which requires your medical clearance 1) due to the "yes" response(s) on the

Health History/Physical Activity Questionnaire and/or 2) the individual is over 40 years

of age and has not been involved in an exercise program on a regular basis.

Your patient will be involved in an exercise program that will be based on the ACSM's

standards for exercise. He/She will be participating in cardiovascular exercise, strength

training, and flexibility during their exercise appointments.

Please indicate below if you approve of your patient's participation in our one-on-one

personal training program. Thank you.

____ I know of no reason why the applicant may not participate.

____ I believe the applicant can participate, but I urge caution because

____________________________________________________

____ The applicant should not engage in the following activities

____________________________________________________

____ I recommend that the applicant NOT participate

Physician signature ____________________________

Please Mail Back to:

Physician Name Printed ________________________

2111Volunteer Blvd.

University of Tennessee

Date ___/___/______

Knoxville, TN 37966

ATTN: Tee Ezell,

Address ________________________

Rec Sports Fitness Director

OR Fax to:

________________________

(865) 974-3477

Phone ( ___ ) ____-______

ATTN: Tee Ezell,

Rec Sports Fitness Director

Medical Clearance Form - Recsports