Medical Release Form printable pdf download

Medical Release Form

Tel:

+44 (0)20 7341 5811

1 Harrington Gardens, London, SW7 4JJ

MEDICAL RELEASE FORM

Dear D octor: _ ________________________________________________ D ate _ ____________________________

Your p atient, _ _________________________________________________, w ishes t o s tart a n e xercise p rogramme

under m y g uidance.

As p art o f t he p re-‐exercise s creening q uestionnaire ( PAR-‐Q), y our p atient i ndicated t he f ollowing a reas, w hich a re o f

some c oncern f or t hem/myself:

During a h ealth/fitness a ssessment, t he f ollowing f actors w ere d iscovered, w hich a re o f s ome c oncern f or m yself:

The p roposed, t ailored e xercise p rogramme w ill c onsist o f t he f ollowing t ypes o f a ctivity:

If y our p atient i s t aking a ny m edication t hat m ay a lter t heir h eart r ate d uring e xercise, p lease i ndicate w hether i t l owers

or r aises t he h eart r ate r esponse:

Medication

Response

Lowers

Raises

Medical Release Form