Medical Release Form printable pdf download

The Campus Recreation Department Fitness & Wellness Program

Personal Training Program

Medical Release Form

Date: _______________________

Dear Dr. __________________________________,

Your patient _____________________________________is interested in taking part in

the Stephen F. Austin State University Campus Recreation Personal Training Program.

The pre-screening process will involve testing of body composition, cardiovascular

endurance, muscular endurance, muscular strength, and flexibility. All assessments will

be administered by a certified personal trainer; qualified in assessment techniques, First

Aid, CPR, and AED.

Your patient has completed a physical activity readiness questionnaire and has

demonstrated concern for medical clearance. By completing this form you are signifying

that there are no medical reasons for which your patient should not participate in the

Stephen F. Austin State University Campus Recreation Personal Training Program.

Please fill out the following:

Please identify any recommendations or restrictions that are appropriate for your patient

in this exercise program:

________________________________________________________________________

Please list any medications that your client is currently taking:

________________________________________________________________________

If your patient is taking medications that will affect their heart rate response to exercise,

please indicate any effect (raises, lowers, has no effect on heart rate response):

________________________________________________________________________

_____ The applicant has my approval to begin an exercise program with the

recommendations or restrictions stated above.

_____ I would recommend that the applicant NOT participate in an exercise program.

Physician’s Signature__________________________ Date: __________________

Phone: ____________________

Client’s Printed Name __________________________

Thank you for taking the time to fill this out.

Medical Release Form