Medical Release Form


+44 (0)20 7341 5811
1 Harrington Gardens, London, SW7 4JJ
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:  


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